Advance Directives are documents that a resident has made and which are used when he or she can no longer make decisions. The form and power of the documents varies from state to state.
- They may appoint a person(s) to make medical, financial or lifestyle decisions for the resident
- They may be statements about what care the resident would want and under what circumstances
- They can be changed whenever a person’s circumstances change or he / she wishes to change them.
In residential aged care (RAC), these documents assist nurses, other health care providers and families to make decisions consistent with the resident’s wishes when residents cannot make their own decisions.
These documents need to be stored safely. However, they also need to be accessible to staff making decisions about care and to visiting service providers. Copies should accompany any resident leaving the facility for medical or hospital care.
This is a complex area of care. The information on this page is of a general nature. Health care providers developing a facility policy or discussing advance directives and care planning with residents and substitute decision makers should be aware of the relevant laws in their state or territory.
Where confusion may arise
Under common law principles people are considered to have capacity to make decisions about their health care unless there is evidence to the contrary. A person with impaired cognition may still have capacity to make decisions about their care. An assessment of capacity should be made at a time of day when the resident is most likely to understand and when he / she is free of pain or other distressing symptoms.
If required an assessment of capacity will usually be made by the resident's GP and may include information from staff who know the resident well. If there is uncertainty over a resident’s capacity it may be appropriate to refer to a psychogeriatrician.
A person is considered to have capacity if they can understand the information, and retain it long enough to indicate their wishes.
Substitute decision makers
- An advance directive cannot include direction for all the possible decisions that may need to be made. The resident should talk about their wishes with the people that they expect to make decisions on their behalf. This ensures that the substitute decision makers are willing to accept the responsibility. A substitute decision maker is someone appointed to make decisions on behalf of a person who has lost capacity to make their own decisions.
- A substitute decision maker is required to make decisions in the best interest of the person and taking into consideration their views as far as they are known.
When there is no advance directive
It is not compulsory to make an advanced directive. Some people may find it too confronting, or may not wish to for cultural or other reasons. The law in most states is very specific as to who may be appointed as a substitute decision maker, when a person has not made a valid appointment before losing capacity to do so.
This is not always the closest relative; it must be a person over the age of 18 who has a close and continuing relationship with the resident. If there is disagreement or uncertainty about who should make decisions, and what decisions they can make, the matter should be referred to the Public Advocate or Guardian in your state.
- The draft revised Standards for Aged Care identifies advanced care planning as an outcome under Standard 2.
- The National Framework for Advance Care Directives was published in 2011. It is a document that is intended to guide and inform legislators and healthcare planners.
- RAC managers and senior staff implementing a program to assist residents complete an Advance Care Directive (ACD), or developing policy on ACDs will find it useful.
Not all states recognise advance directives from other states. If a resident has advance directives from another state to the one they are now living in, a RAC manager should check their validity with local authorities.