Making your preferences for care known

What it is

Related Resources

Advance care planning (ACP) is a process of discussing values and preferences for care. These preferences only guide care when a person loses decision-making capacity or the ability to communicate.

Advance care planning is an ongoing conversation that has many possible outcomes. It can start at any age or stage of health or in any setting: hospital, primary care, specialist care.

These conversations and any records can be revised at any time.

Advance care planning terminology

Advance care planning is a process of discussing values and preferences for future care. This might inform care decisions if a person loses decision-making capacity or the ability to communicate.

An advance care plan states a person’s preferences about their health and personal care. An advance care plan is not the same as a clinical care plan, treatment plan or resuscitation plan. An advance care plan is not a legal document.

Advance Care Directives are a legal record of a person’s preferences for care and treatment and can be one of two types of documents:

  • instructional (enable the person to make decisions about their future medical treatment.) or
  • appointing (enable the person to appoint someone to make health care decisions on their behalf in the event they are unable to do so themself).

A substitute decision-maker is a person who is appointed/nominated in an ACD to make a decision on behalf of a person who lacks the capacity to make their own decisions.

Why it matters

The aim of advance care planning is to:

  • support a person’s autonomy (if wanted) and decision-making
  • help ensure care is consistent with a person’s values and preferences
  • avoid unwanted treatments
  • assist family with the process of making emotional and sometimes difficult decisions

In practice

Nurses have a role in educating the people in their care about the importance of advance care planning. You can assist people in your care to make a plan that is appropriate for them. Supporting the person to think about what is important for them and encouraging them to have conversations with family, significant others, and healthcare providers can help. Recording their wishes, values, and preferences, helps others to know what they would want should they be unable to communicate this in the future.

Ideally, advance care conversations should begin when a person is medically stable, comfortable, and accompanied by their substitute decision-maker(s), family, friends and/or care.

Many people expect health professionals to initiate discussion of their preferences about future care.

Triggers for advance care planning conversations can include:

  • when a person or family member asks about current or future treatment options and goals
  • when there is a diagnosis of a metastatic malignancy or end-stage organ failure, indicating a poor prognosis
  • when there is a diagnosis of early dementia or a disease which could result in loss of capacity
  • if you would not be surprised if the person died within twelve months
  • if there are changes in care arrangements (for instance, admission to a residential aged care facility)

Nurses may become involved in advance care planning with people in their care. Each State and Territory has different legislation regarding advance care plans and Advance Care Directives (ACD). Use Advance Care Planning Australia (ACPA) to understand the legal aspects of ACP for each state and territory. 

An informed advance care plan requires an understanding by the person of their own health problems, and about the realistic implications of the possible treatment options. The person’s ability to make decisions is an important consideration.

Making wishes known and respected

Video by Dr Karen Detering

This information was drawn from the following resources:

  1. Austin Health. Advance Care Planning Australia [Internet]. 2021 [cited 2022 Aug 12].
  2. Australian Government Department of Health and Ageing. A national framework for advance care directives (2.22MB pdf). Canberra: Australian Government Department of Health and Ageing; 2011.
  3. Izumi S. Advance care planning. 2019. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing. 5th ed. Oxford: Oxford University Press; 2019. [cited 2022 Aug 12].
  4. Queensland University of Technology (QUT) - End of Life Law in Australia. Advance Care Directives [Internet]. 2022 [cited 2022 Aug 12].
  5. White BP, Willmott L, Tilse C, Wilson J, Ferguson M, Aitken J, et al. Prevalence of advance care directives in the community: A telephone survey of three Australian States. Intern Med J. 2019 Oct;49(10):1261-7. doi:10.1111/imj.14261.

Page created 15 August 2022