About advance care planning

Supporting people's preferences

Advance care planning is a process of planning for future health and personal care.

Through conversations and a written plan, a person can share their values, beliefs and preferences with their loved ones and healthcare team. If, in the future, the person is unable to make or communicate decisions, their advance care plan will guide family and doctors in making treatment decisions.

Care workers, general practitioners and general practice nurses can help a person make informed decisions for their future care. A person may ask you for help in making an advance care plan, or you may want to start the conversation with them.

Advance care planning is a series of conversations that a person has with their family, friends, carers, nurses and/or doctors about their future healthcare preferences. These preferences can be documented in a written advance care directive. An advance care plan only comes into effect if a person does not have decision-making capacity. 

As part of their plan, a person may choose someone they trust to make treatment decisions on their behalf. A substitute decision-maker is only called upon if the person cannot make or communicate decisions themselves. 

Advance care planning can happen with assistance from trained health professionals; however people can choose to discuss their advance care plans in an informal family setting.  

There are very significant differences between advance care planning and euthanasia. Advance care planning is the process of discussing and choosing future health care and medical treatment options. It is about people making decisions about their own medical treatment including refusing treatment. Euthanasia is the practice of intentionally ending life in order to relieve pain and suffering. Euthanasia is currently illegal in Australia.

An advance care planning discussion will often result in an advance care plan. The plan can be written down on paper in an advance care directive. This document states preferences about health and personal care, as well as preferred health outcomes.

An advance care plan may be made on the behalf of a non-competent person, and should be prepared from the person’s perspective to guide decisions about care.

In an emergency, medical decisions will be made by the doctors. The clinician will take the person's wishes into account, by referring to a person's advance care directive and/or talking to the person's substitute decision-maker and family.

If the advance care directive is not immediately available, life-prolonging measures may be started until the treating doctors discuss expressed wishes with the substitute decision maker and family.

In the event of serious illness doctors will make treatment decisions based on best interests. This may include treatments that the patient would not want.

Yes, a person can legally refuse treatment before or after it has been commenced. In some states, substitute decisions-makers can also refuse treatment on behalf of the person who has lost capacity. You can learn more about differences in advance care planning between states/territories on Advance Care Planning Australia's website.
Serious illness or injury can happen to anyone. Making a plan, and discussing it with loved ones and doctors can offer everyone peace of mind.

But planning is particularly important in several scenarios. Triggers for advance care planning can include:

  • if the answer to 'Would I be surprised if this patient died within the next 12 months?' is 'No'

or if a person:

  • raises advance care planning with a member of the general practice team
  • has an advanced chronic illness (for example: COPD or heart failure)
  • has a life limiting illness (for example: dementia or advanced cancer)
  • is aged 75 years or older, or 55 years or older if they are an Aboriginal and/or Torres Strait Islander person
  • is a resident of, or is about to enter, an aged care facility
  • is at risk of losing competence (for example: has early dementia)
  • has a new significant diagnosis (for example: metastatic disease or transient ischemic attack)
  • is at a key point in their illness trajectory (for example: recent or repeated hospitalisation, or commenced on home oxygen)
  • does not have anyone (such as a family, caregiver or friend) who could act as substitute decision-maker
  • may anticipate decision-making conflict about their future healthcare
  • if the patient has a carer.

A person must have the capacity to make decisions in order to make an advance care plan or to choose a substitute decision-maker.

A person with capacity should know the decision facing them, understand the possible options available as well as their outcomes, be able to understand and retain the information, use or weigh the information and finally communicate the decision.

Their competence or capacity is assessed during the process of an advance care planning discussion.

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Advance care planning

Principles and benefits

Watch our webinar series to understand the impact changing health can have on people and their families, and to learn how and when to have the advance care planning conversation.

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Advance care planning

Educational resources

We're here to help aged care workers, general practitioners and nurses improve their skills and increase their knowledge in advance care planning.

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Related resources

  • Fact sheet

    Advance care planning fact sheet for individuals and family

    Advance Care Planning Australia

    Information about advance care planning for individuals and their families.

  • Articles & Publications

    Advance care planning workbook

    Central Coast Local Health District

    A step-by-step workbook for individuals, carers and families on how to approach, discuss and start documenting your advance care planning preferences.

  • Form

    Advance Care Plan - Form/Template (VIC)

    Victorian Government

    The state of Victoria offers a template that a person may fill out or use as an example to write their own advance care directive. Write down specific information relating to your wishes, values and any treatments you would not wish to receive.

  • Website

    Advance Care Planning Australia

    Advance Care Planning Australia

    Advance Care Planning Australia (ACPA) is a national program funded by the Australia Government Department of Health, enabling Australians to make the best choices for their life and health care.