Personal Preferences
Decisions about transfers should respect and involve the person at every step.
- The person is excluded from decisions about their care and transferred against their wishes.
- A substitute decision-maker is not consulted when the person lacks capacity.
- The person isn’t provided with clear, accessible information to inform their decisions.
- Preferences outlined in Advance Care Directives or care plans are not followed.
- Provide relevant and understandable information to the person or their substitute decision-maker before discussing transfer options.
- Ensure Advance Care Directives and care planning documents are:
- up-to-date and reflect the person’s needs and preferences
- easily accessible to staff for guiding decisions, including transfers.
- Regularly check with the person (or substitute decision-maker) to confirm they have the information they need and feel heard.
- Review care plans to ensure preferences are documented and respected.
The person is central to decisions about transfers
- The person must be involved in all decisions about their care, including transfers.
- Consent is required from the person or their substitute decision-maker (except in emergencies).
- Their preferences, beliefs, and values—whether cultural, faith-based, or personal—must be respected.
- If they choose not to transfer or receive treatment, their decision should be honoured to support their dignity and choice.
Supporting end of life in residential aged care
Many people prefer to stay in residential aged care (their home) rather than be transferred to hospital. They have the right to die in a familiar, comfortable place with support from staff who know their needs and preferences.
Aged care facilities should provide a suitable environment for quality end-of-life care and support family involvement if the person wishes.
The person has a right to refuse transfer
People have the right to make their own care decisions, even if there are risks. They may choose not to be transferred for treatment, and this should be respected. Forcing transfers or treatment against their wishes may lead to unwanted or non-beneficial treatment, and cause unnecessary distress for them, their family, and healthcare staff.
Discussing a transfer
When talking about a transfer with a person (or their family, friends, or substitute decision-maker), provide clear information on:
- why the transfer may be needed
- possible transfer locations
- risks and benefits of the transfer
- alternatives to avoid transfer, such as extra support.
If there is disagreement, it should be discussed and resolved. Ref 19
Preferences may be captured in Advance Care Plans
The Strengthened Aged Care Quality Standards require aged care providers to regularly assess and plan with residents to understand their current needs, goals, and preferences. This includes planning for future care, such as advance care planning and end-of-life planning, if the person wishes. If the person has expressed preferences about transfer and treatment in an Advance Care Directive or other care planning documents, these should be known and respected. These documents should be kept where all staff can see them and shared during transfer if the person consents.
Respecting the person's preferences
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Others may support decision-making
Some people may choose to involve their family, friends, or health professionals to help them make decisions about their care and treatment. If the person is unable to make decisions for themselves (as determined by their doctor), a substitute decision-maker can make decisions about their medical treatment on their behalf.
Special considerations apply in emergency situations
Important things to know:
- If the older person for has Advance Care Planning Documents (e.g. Advance Care Directive), a resuscitation plan, and/or substitute decision-maker, and what the residents’ documentation says about treatment.
- How to respect the person’s treatment decision. Remember that it is lawful for a person with capacity to refuse to go to hospital or to receive life-sustaining treatment even if it will result in their death.
- Your workplaces’ policies and procedures in relation to emergency situations.
- What the law in your State or Territory says about providing treatment.
More information about treatment, transfers and care for people with and without capacity can be found in the ELDAC End of Life Law Toolkit.