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.
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:
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.
The aim of advance care planning is to:
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:
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.
Visit Advance Care Planning Australia (ACPA)
Advance Care Planning Australia
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.
Video by Dr Karen Detering
This information was drawn from the following resources:
Visit the Advance Care Planning Australia website
Read Guidelines for electronic ACP documents (8.8MB pdf)
For more Advance Care Planning Resources
Page created 15 August 2022