Advance Care Planning

Just Better Care supports and respects our customers' rights to make informed decisions about treatment and their end-of-life preferences.

This includes the customer’s right to discuss their choices and to document their decisions, which will be used if they cannot communicate their choices and preferences due to deterioration, acute illness, or injury.

What is advance care planning?

Advanced care planning is a powerful tool that empowers individuals to plan for their future health and personal care needs. It allows them to express their values and preferences, giving them a sense of control over their future decisions even if they cannot communicate them.

Advanced care planning helps people determine their healthcare priorities, aligning their health and care preferences with the actual care they receive.

Advance care planning is not a single event but an ongoing process that should be revisited regularly. This is especially important when a person’s health or social situation changes.

Key components of advance care planning are:

Having a conversation about the person’s values, beliefs, cultural and linguistic preferences, and goals and how these influence preferences for care – this may include specific care and treatment preferences;

Identifying and implementing shared care planning;
Selecting and appointing a substitute decision-maker;
documenting a person’s preferences in an Advance Care Directive or Advance Care Plan; and,
regularly reviewing and updating the plan or directive.

What is an Advance Care Plan?

Advance Care Plans state preferences about health and personal care and preferred outcomes.

An advance care planning discussion often results in a written plan. Depending on the person's capacity to make healthcare decisions, the plan may be made by themselves or someone else. The plan will consider the person’s perspectives and values to guide care decisions.

Suppose an Advance Care Plan is made for an individual with impaired capacity. In that case, it is formulated with the substitute decision-maker and/or other people who know the person well and aim to reflect what they would document for themselves if they could do so.

What is an Advance Care Directive?

An Advance Care Directive is a type of written Advance Care Plan recognised by common law or specific legislation completed and signed by a competent adult. It may record the person’s values and preferences for future care and/or include the appointment of a substitute decision-maker to make decisions about health care and personal life management.

An instructional directive is a specific type of Advance Care Directive that outlines particular treatment they would or would not like to receive and under what conditions. Each state and territory has different forms and requirements for instructional directives, so familiarising yourself with your jurisdiction’s legal requirements and documents is essential.

Other types of written plans

Documentation of advance care planning can also be informal. It can include:

non-statutory forms;
personally written letters;
a written plan outlining a person’s values, beliefs and specific goals for care; and,
letters or documents written by a professional outlining the person’s preferences.

An Advanced Care Directive is considered personal information, and the collection, use, and storage are subject to privacy laws. You should keep a copy of the original document or indicate if the original is kept with someone else, such as a solicitor or enduring guardian.

What is a substitute decision-maker?

A substitute decision-maker is a person appointed or identified by law to make decisions on behalf of a person with impaired decision-making capacity. Substitute decision-makers have legal authority to make these decisions; the relevant legislation varies between jurisdictions (states and territories).

An advance care directive is a document that appoints a substitute decision-maker to make health, medical, residential, and other personal decisions (but not financial or legal).

There are three categories of substitute decision-makers. They may be:

chosen by the person;
assigned to the person by law in the absence of an appointed substitute decision-maker (default substitute decision-maker); and,
appointed for the person (e.g. a guardian appointed by a guardianship tribunal).

Benefits of Advance Care Planning

Advance Care Planning benefits the person, their family and others who care for them. Some of the benefits include:

improved end-of-life care;
increased likelihood that the person’s preferences are known and respected;
improved psychological outcomes for surviving relatives and reduced stress and anxiety for family members in making decisions;
fewer inappropriate transfers from residential aged care to hospital; and,
higher staff satisfaction for those caring for persons in aged care facilities.

Advance Care Planning Australia has designed a booklet and a factsheet for individuals to assist individuals with information about advanced care planning.

As part of National Advance Care Planning Week, a free community webinar will be held on March 19th, 2025. This webinar is designed to provide all the necessary information and guidance to start the advanced care planning journey, ensuring all participants are well-informed and prepared.
National Advance Care Planning Week aims to raise awareness about advance care planning and its benefits to all Australians.

Contemporary advance care planning free online webinar with Dr Greg Parker and Dr Craig Sinclair

Advance Care Planning Australia is hosting a webinar with Dr Catherine Joyce, the national manager of Advance Care Planning Australia, and Judith Leeson, AM, who will offer a community and personal perspective on the value of advance care planning.
This national webinar suits everyone interested in learning more about Advance Care Planning.