Advance Care Planning

Advance care planning (ACP) is  a process of discussion about goals of care and recording of preferences for care of people who may lose capacity or communication ability in the future.

The Public Health approach to palliative care advocates open discussions about ACP in the wider community. With ACP, the emphasis is on thinking about values and decisions and then talking to those around you about them.

ACP may include creating formal documents known as advance care directives or developing clinical care plans for future medical events. Nurses may become involved in ACP with their patients and families or individually for themselves and their own family. Each State and Territory has different legislation regarding ACP and Advance Care Directives (ACD), and nurses will need to know what applies in their area of practice.

Individual organisations (hospitals, area health authorities, community health services) may also have policies or procedures in place that relate to ACP.


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Clinical Evidence

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Abel J, Pring A, Rich A, Malik T, Verne J. The impact of advance care planning of place of death, a hospice retrospective cohort study. BMJ Support Palliat Care. 2013 June;3(2):168-73. Epub 2013 Mar 15. 

Silvester W, Parslow R, Lewis V, Fullam R, Sjanta R, Jackson L, et al. Development and evaluation of an aged care specific Advance Care Plan. BMJ Support Palliat Care. 2013 June;3(2):188-95. Epub 2013 Mar 15.

Gaw A, Doherty S, Hungerford P, May J. When death is imminent: Documenting end-of-life decisions. Aust Fam Physician. 2012 Aug;41(8):614-7.

Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010 Mar 23;340:c1345.

Seymour S, Almack S, Kennedy S. Implementing advance care planning: a qualitative study of community nurses’ views and experiences. BMC Palliative Care. 2010 Apr 8;9:4.


  • The Advance Care Planning Australia website has information on Australian processes for each state and territory
  • From Dementia Australia National Quality Dementia Care Initiative the Start2talk website.

Guidelines / Documents / Factsheets

Last updated 25 January 2017