Key messages

  • The Department of Health and Human Services has funded research to support the implementation of advance care planning.
  • All public healthcare services completed the scoping survey, which informed the department on progress towards implementing the advance care planning strategy.

The Department of Health & Human Services has funded a number of projects to support implementation of advance care planning from different perspectives.

Advanced care planning forms

The Department of Health & Human Services in close collaboration with the Office of the Public Advocate, has created standardised advance care directive and appointment forms, as well as accompanying instructions.

These forms are useful advance care planning tools that allow Victorians to write a legally binding advance care directive, appoint a medical treatment decision maker and appoint a support person.

These forms are available for download on the advanced care planning forms page.

Scoping survey

Austin Health led a scoping survey to determine the progress being made by Victorian health services in implementing the advance care planning strategy at the local level. All public healthcare services completed the first scoping survey.

Key findings

  • Health services have, or are putting in place, systems to deliver advance care planning across the organisation.
  • Executive leadership is predominately strong.
  • While implementing advance care planning can be challenging, clinicians understand the benefits and have strong commitment to successful implementation.

Areas for improvement

  • Mentoring for staff to consolidate advance care planning skills.
  • Working with consumers at risk of cognitive decline.
  • Expanding advance care planning beyond palliative care and residential aged care facilities.


The gaps in, barriers to, and strengths of advance care planning implementation were presented to the Advisory Group in December 2014. Initiatives have begun to overcome the barriers and gaps identified by the survey.


Developed by Barwon Health, MyValues is an online tool that provides a set of specially constructed statements designed to help people identify, consider and communicate their wishes about the medical treatment they would want in the later stages of life. 


MyValues is available online and is an option for people wishing to complete an advance care plan. 

System-wide advance care planning

The department engaged Networking Health Victoria to help Victorian Primary Health Networks to support health services and their partners to implement and sustain advance care planning throughout and across their organisations.

Hume, Inner North West and Barwon primary care networks were the successful consortia. They are being supported to improve the uptake, scalability and transferability of advance care planning statewide, and to incorporate advance care planning into ‘usual care’ within their local areas.

The three consortia represent rural, regional and metropolitan Victoria. Hume has the additional challenge of engaging interstate, across New South Wales and Victoria.


Tools and techniques for implementing advance care planning consistently across Victoria will be available to other regions by December 2016.

Transferability options paper

Austin Health is investigating how to improve transferability of advance care plans across organisations, which is a key goal of the advance care planning strategy.

Austin Health is working with a wide range of stakeholders to better understand the systems that organisations use, as well as barriers to and requirements for, transferring advance care plans.


The transferability options paper will be presented to the Advisory Group in late 2015.

Resources to support health professionals

This resource comprises nine modules to support Victorian doctors and other health professionals to:

  • ‘have the conversation’ with patients about end-of-life decision making
  • engage patients in decisions about their care
  • help them to undertake advance care planning.


Download Advance care planning: resource for doctors. The department and AMA Victoria are working to make this resource available as an interactive tool in 2016.

Having difficult conversations factsheet

To complement the work being undertaken by Australian Medical Association, Northern Health is developing a simple ‘cheat sheet’ to support clinicians when having difficult conversations with consumers and their families and carers about advance care planning.


The difficult conversations ‘cheat sheet’ will be available in 2016. 

Guidelines to support conversations when caring for very sick children

Following a comprehensive literature review and evaluation of current practice, The Royal Children’s Hospital has developed a guideline and  tool for clinicians to have conversations about advance care planning with the families of very sick children.


The resource includes a list of recommended clinical triggers for advance care planning, and examples of appropriate language to use with families and will be available in 2016.

Understanding decision making doctor, consumer and substitute decision-makers

Alfred Health undertook research to find out whether families and clinicians find advance care plans useful for decision making.


The research suggests that, while advance care plans can guide decision making, they aren’t always enough in complex medical scenarios to ensure that an individual’s choices are respected. The researchers recommended that people should be encouraged to talk to their families and other loved ones about their values and preferences for quality of life, and that clinicians should support them to talk about their preferences for medical treatment.

Diverse cultural groups and advance care planning

Northern Health interviewed thirty-nine hospital interpreters, representing over twenty language groups.


Results from the interviews suggest that there is considerable diversity within CALD communities for how medical decision-making, especially at end-of-life is approached. Issues to consider:

  • Level of health literacy, including understanding of health systems and health-related law in Australia.
  • Approaches to moral reasoning, and how different or similar this is to the clinicians.
  • Concern for helping one’s family, rather than autonomy, may be a driver for some people to do advance care planning.
  • Some people may be reluctant to discuss death and may hold superstitions about this.
  • Advance care planning education may best be done by working with established and trusted community groups.

Developing resources for consumers

The Health Issues Centre is leading a project to gauge consumer understanding and perceptions of advance care planning. The centre held eight focus groups with consumers. Preliminary results from the focus groups suggest that:

  • people are reluctant to document healthcare decisions in the absence of specific health circumstances
  • substitute decision-makers report feeling unprepared; they want guidance and support from professionals
  • past experience, family dynamics and relationships play a significant role in approaches to advance care planning
  • there is confusion regarding the definition of advance care planning and its components.


The project has recommended strategies for increasing community awareness about advance care planning, and resources to support conversations and informed decision making.

Developing resources for consumers from different cultural backgrounds

The Ethnic Communities’ Council of Victoria is working with Filipino, Macedonian, Serbian and Turkish groups to understand how advance care planning can be best undertaken with people from these cultural groups.


The project will develop resources that meet the needs of, support community education programs for, each of the communities.