What is it?

Advance care planning is a process that enables a person to express their wishes for care, levels of treatment and acceptable health outcomes.

When an advance care plan is documented it can guide clinical decision-making should a person be unable to participate in making decisions for themselves.1 

Advance care planning is a values-based approach with two main aspects:

  • discussing and documenting, a person's wishes in an advance care directive.
  • appointing a medical treatment decision maker. 

In Victoria, a person can create a legally binding advance care directive. A person’s advance care directive can include general statements about their values, medical preferences and what they would like their medical treatment decision maker to consider when acting on their behalf. It can also include instructional statements, in which a person may consent to or refuse a particular medical treatment. 

However, people may use a range of documents to express their values and preferences for care and treatment. Health services must give due consideration to a person’s advance care planning documentation, whatever form it takes.

Why is it important?

Advance care planning has wide-ranging benefits including:

  • improving the quality of life of the older person
  • reducing the stress and anxiety in family members2
  • supporting clinicians to provide person-centred care
  • improving professional satisfaction.

’Advance care planning helps to give me an ongoing voice in the level of medical treatment and quality of life I want, while I can still have my say.’ Maryan Tozer, healthcare consumer.

How can you guide a person in advance care planning?

All healthcare professionals have a shared role in providing the best care for older people. Person-centred care is central to advance care planning and involves having a conversation with a person about their future health outcomes and respecting their choices.

Make it part of your daily practice

There is no better time than now to have a conversation about advance care planning – it is a conversation that needs to happen over time, not just at the end of life. Advance care planning needs to be embedded into an older person’s usual care.

Having the conversation

Communication, particularly the skill of listening, is central to good advance care planning.

Older people rely on the expertise of the medical team to guide their decision making and to initiate a conversation to assist them to clarify their priorities. Having a values-based conversation provides you with an opportunity to encourage an older person to explain what is important to them and for you to assist them to document their goals.

Some ways to start the discussion about advance care planning include:

  • ‘Your health is quite good at the moment, so now is a good opportunity to talk about the future.’
  • ‘Let’s talk about what would happen if you couldn’t make decisions.’
  • ‘Who would make decisions for you and would they know what you would want?’

Some things to keep in mind

  • Listen to the person – encourage them to express their fears, wishes and feelings. Ask them how they’re coping, and look for potential cues which may indicate that they want to discuss future plans.
  • Be honest, straightforward and sensitive.
  • It is often helpful to introduce the idea of advance care planning first, and discuss in more detail later.
  • Encourage the person to speak with their family, friends and treating team about their wishes for future care.
  • Consider health outcomes in terms of pain, cognition, eating, mobility, continence and what the person would find acceptable and the compromises they would be willing to make.

What to do after the conversation

You can help a person document their advance care plan in the following ways:

  • Follow your health service’s policy.
  • Give the person an advance care directive form. If your health service does not have one, there is a template available on the advance care planning forms page.     
  • Create an alert in the medical record that a person has an advance care directive and/or an appointed medical treatment decision maker.     
  • Document the conversation and decisions on an advance care planning discussion record.

Encourage or assist the person to:

  • Write down their wishes for medical treatment in an advance care directive.
  • Appoint a medical treatment decision maker.
  • Have a conversation about their future preferences and choices with their family and friends, particularly their medical treatment decision maker.
  • Provide copies of their advance care directive to their medical treatment decision maker, GP, local hospital, and those involved in providing their care.
  • Keep the originals. 

1. Department of Health 2014, Advance care planning: have the conversation. A strategy for Victorian health services 2014–2018, State Government of Victoria, Melbourne.

2. Detering KM, Hancock AD, Reade MC & Silvester W 2010, ‘The impact of advance care planning on end of life care in elderly patients: randomised controlled trial’, British Medical Journal, 340.

Advance care planning fact sheet for clinicians