Advance Care Planning

Advance care planning involves talking about and documenting a person’s values, preferences, and decisions about future care including end of life. It helps ensure an individual’s choices are known if they are unable to communicate. You can introduce and encourage these discussions at different points along the older person’s care journey.

Read the supporting evidence

What I can do

Advance care planning helps people plan ahead. Consider raising it:

  • If they have a serious illness, early dementia, or signs of decline
  • After a hospital stay, new diagnosis, or moving into residential aged care
  • If they express concerns about the future or recall difficult past experiences with death and dying.

Creating the right environment for these discussions is important. To help people feel at ease:

  • Choose a quiet, private space and allow enough time
  • Provide hearing aids, communication aids, or an interpreter if needed
  • Involve a trusted friend or family member if they wish.

Clear documentation helps ensure wishes are respected. You can support this by:

  • Helping the person clearly state their preferences
  • Encouraging them to share their plan with family and healthcare providers
  • Storing advance care planning documents in an accessible place such as My Health Record.

Tips for Careworkers: Advance care planning

Tips for Nurses: Advance care planning

What I can learn

The palliAGED Practice Tip Sheets give helpful guidance on supporting older people with advance care planning near the end of life. There is a version for nurses as well as careworkers.

You can also build your skills with these eLearning modules (free: registration required):

Access these resources to understand the legal aspects of advance care planning:

 

What I can give

If an older person, their family or carers wishes to learn more about advance care planning, these resources may help:

Older people, their family and carers can also receive support and guidance from the National Advance Care Planning Support Service:

 

What I can suggest

Ensure processes are in place to make advance care planning documents accessible by:

  • Using standardised forms
  • Storing them in a safe, accessible system (e.g. My Health Record)
  • Having clear processes for updating and sharing them with the full care team.

Staff confidence in advance care planning improves with proper training. Your team can:

  • Offer training using the guides from Advance Care Planning Improvement (ACPI) Toolkit
  • Develop scripts or templates to help staff start advance care planning discussions
  • Provide mentoring or role-playing exercises to build confidence in having sensitive conversations.

Making advance care planning part of routine care planning improves outcomes. Suggest:

Page updated 06 June 2026