The process of advance care planning should begin before a person requires community or residential aged care services. However, the uptake of advance care planning in the community is low and the majority of older Australians do not have an advance care directive.
General practitioners and aged care teams play a key role in advance care planning so it’s important for them to have a good understanding of what advance care planning is and what’s involved in the advance care planning process.
Community aged care
Clients receiving community aged care services under the Commonwealth Home Support Programme and Home Care Packages are likely to have chronic conditions and be frail but may still have capacity to make decisions. Community aged care providers are in a better position than hospitals or residential aged care providers to commence advance care planning with clients, as community aged care clients are less likely to have cognitive impairment and are more likely to be in a stable condition.
Working with health professionals such as general practitioners, community aged care workers can help people undertake advance care planning and create an advance care directive.
Learn more about the responsibilities of community aged care providers.
Residential aged care
Many people admitted to residential aged care have cognitive impairment and may have lost decision-making capacity, which limits their ability to undertake advance care planning.
Residential aged care providers can still play a key role in advance care planning by:
- identifying if a resident has an advance care directive
- identifying the resident’s substitute decision-maker
- talking with residents about their values and preferences, regardless of cognitive capacity, and involving their substitute decision-maker and others, such as family, in the conversations
- ensuring timely sharing of information with other services and healthcare providers when capacity is lost and a care or medical decision is required or if transfer of care is required
- helping the resident’s family or loved ones to create an advance care plan. Find advance care plan forms for your state or use our form advance care plan for a person with insufficient decision-making capacity which can be used in all states and territories.
Learn more about the responsibilities of residential aged care providers.
Training and education
Undertaking training and education is the best way for aged care workers to improve their knowledge and their confidence to have advance care planning conversations. We support aged care workers to learn about advance care planning through a range of online courses, workshops, webinars and information sessions.
Find out more about training and education opportunities.
Guide for aged care providers
Our guide Advance care planning in aged care: A guide to support implementation in community and residential settings offers comprehensive information on advance care planning, specific to the aged care sector; from engaging with patients and families, policies and procedures and legal aspects relevant to each state and territory.
Copies of the printed guide are also available to order.
Advance Care Planning Improvement Toolkit
Our Advance Care Planning Improvement Toolkit aims to support organisational advance care planning uptake, performance monitoring, and quality improvement. Learn more about how you can use the toolkit in your workplace.
Part of life - ELDAC resources
Part of Life campaign aims to support those working in aged care to talk about end-of-life with the people you care for, and shows how it can improve the care you provide.