Advance care planning documentation

Australian states and territories have developed documents and resources to assist people to record their advance care plan; see state health department websites or Advance Care Planning Australia. The plan may be known as an advance care plan, advance care directive, living will or statement of choices; there may be separate documents to appoint a substitute decision-maker or for refusal of treatment. Other expressions of advance care planning are also acceptable and are enforceable under common law; for example, a letter to the general practitioner (GP) or a verbal statement witnessed by an authorised person. Some health services have developed electronic tools (eg online forms) to assist patients to record and share their plans.

Information that may be included in an advance care plan is shown in Information that may be included in an advance care plan.

A patient’s GP or other doctor may assist them to record an advance care plan, or, in some health services, a specialist nurse or other trained staff may assistMitchell, 2014. The patient’s decision-making capacity should be considered when undertaking this process—adults are presumed to have capacity unless it is established that they do not have capacity.

Patients’ goals and preferences may change over time and advance care plans should be reviewed regularly; for example, annually or when a patient is hospitalised or their condition changes. If changes are made, the old version should be updated or replaced and relevant people notified.