| TOPIC | Advance Care Planning Procedure – Internal | ||
| AREA | Service Delivery | TYPE | Procedure |
1. Purpose
Mobility is committed to delivering safe, consumer focused care and support in accordance with the consumer’s assessed needs, individual goals, and preferences to optimise their health and wellbeing.
The purpose of this procedure is to guide staff in providing consumer directed support based on a wellness approach when assisting people with Advance Care Planning, in ongoing partnership with the consumer and others they wish to be involved in the assessment, planning and review of their services, such as the substitute decision maker.
2. Scope
Evidence suggests that Advance Care planning conversations are often left too late which can cause distress for the consumer, consumer’s representatives, substitute decision makers, family and carers and members of the workforce when the consumer’s wishes are unknown.
The consequence may also be that the consumer does not have the experience they would have wanted.i It is never too early in life to document wishes in a formalised Advance Care Plan or Directive. This is a basic human right to do so.
This procedure applies to mobility care managers, clinical and risk specialist and Carelynx RN within their individual scope of practice to provide care and support that optimises the consumer’s health, wellbeing, dignity, privacy, and comfort. Recognition is given to the person’s cultural, religious, spiritual beliefs’, physical needs, and choices.ii
the End-of-Life Care Procedure should be referred to as required.
3. Definitions
| Advanced Care planning (ACP)* | Advance care planning (ACP) is an ongoing discussion between a consumer, their carers/family, and their health care professionals, about their values, beliefs, treatment, and care options. In particular, their wishes for future care should they no longer be able to communicate their decisions at the time they are needed. |
| Advance Care Directive (AHD) * | An advance care directive (AHD) is an important part of end-of-life care. An advance care directive formalises the advance care plan. The directive can contain all the consumer’s needs, values and preferences for future care and details of a substitute decision-maker. |
| Capacity | The ability to decide for oneself and can be assessed by trained professionals. Capacity assessment does not assess whether the decision is considered “good” or “bad” by others such as clinicians or family but considers the person’s ability to decide and comprehend its implications. When a person has capacity to make a particular decision, they can do all of the following: · understand and believe the facts involved in making the decision By default, people are assumed to have capacity, unless there is evidence to the contrary. |
| Consent | Informed consent means that a person: · is provided with appropriate and adequate information An individual cannot give valid consent if they lack the capacity to make an informed decision. |
| Delirium and Loss of decision-making capacity | Temporary loss of decision-making capacity, the advanced care directive is only in place until the consumers regains decision making capacity. |
| Inclusive decision- making | Including consumers in the decision-making process is fundamental to meeting the principles of consumer directed care and ensure that consumers receive the best care possible that will allow them to make informed decisions that align with their present intentions and future desires. |
| Substitute decision maker | · Substitute decision-maker is a person appointed or identified by law to make substitute healthcare decision(s) on behalf of a person whose decision-making is impaired. A substitute decision- maker may be appointed by the person, appointed for (on behalf of) the person, or identified as the default decision- maker within legislation. Substitute decision-makers listed in Advance Care Directives are statutory appointments. · Substitute decision-makers listed in advance care plans are not legally binding. |
4. Roles and Responsibilities
Care Managers
- Provide care and services as per mobility’s policies, procedures and work instructions and the consumer’s care plan.
- Demonstrate empathy and sensitivity to the needs of the elderly from a variety of ethnic, cultural, and religious backgrounds (See Diversity and Inclusion Procedure).
- Identify if a consumer has an AHD at the onboarding process (see the on-boarding document) and update our records.
- Record the consumers substitute decision-maker and their contact details in
- If a copy of the ACP document is provided, add to mobility portal and document it in the Care
Carelynx RN
- Discuss ACP with the consumer and/or nominee or family
- Document on the consumers record that an ACP is in place and request a
- Provide advice to consumers, nominees, and family regarding ACP, as per this
- Review
- Implementing and enacting ACD and end of life
Clinical and Risk Manager
- Assist Care Managers with
- Assist and support the implementation and enacting of the
Consumers, and their family and/or loved ones (optional)
- Talking about their values and preferences for future health care with
- Selecting and appointing a trusted substitute decision-maker.
- Documenting their preferences in a legally binding
- If the consumer has insufficient capacity, having the substitute decision-maker document the person’s preferences in an ACP to inform care.
- Advising mobility and providing a copy of the ACD (this is recommended, but not mandatory).
5. Procedure
Care Managers are to ask and document if the consumer and/or authorised representative have an ACP in place, ask for a copy, and then advise Carelynx RN.
The Carelynx RN will discuss ACP with the consumer and /or authorised representative as part of the care planning process.
4.1 Process
RN: to support consumers, nominees and family regarding ACP and encourage them to store a copy with them, their substitute decision-maker, GP, treating health service or hospital and in My Health Record or linked to medic bracelets.
The key components of ACP are:
- Having a conversation about the person’s values, beliefs, goals and how these influence preferences for This conversation may include specific care and treatment preferences, including preferences not to receive certain types of care or treatment, and what they consider acceptable and unacceptable health outcomes.
- Selecting, preparing, and appointing a substitute decision-maker.
- Documenting the person’s preferences in an
- For those with diminished or no decision-making capacity, having the substitute decision- maker document the person’s preferences in an advance care plan.
- Regularly reviewing and updating an ACD or
- Sharing the ACD or ACP with all relevant parties and making sure any updated documents are effectively communicated to these parties if and when these documents are revised.
- Activating an ACD if the person loses decision-making capacity and aligning medical treatment decision with their preferences.
The extent to which the person can be involved in the ACP process will be determined by a range of issues, particularly their cognitive capacity, diagnosis, and stage of disease progression.
While the capacity to make decisions is assumed unless an assessment indicates otherwise. People who are competent to make decisions can be fully involved in advance care planning if they choose to be. A person who does not have the capacity to make decisions should be involved to the best of their abilities, along with their potential substitute decision-maker and healthcare team.
If the consumer has an Advance Care plan, staff are to ensure they have a clear understanding of the substitute decision-maker’s role, instructional directives, and the decision-making capacity of the consumer.
Consumers should be encouraged to share their Advance Care plan with other relevant service providers and ensure they or the substitute decision maker understand the implications, consequences and risks associated with such decisions (refer to the Dignity of Risk and Duty of Care Procedure).
- Review the Advance Care Directive
| Who is Involved | When should it happen? | How do you do it? |
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- Activate the Advance Care directive
| Who is Involved | When should it happen? | How do you do it? |
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List by State and Territory End-of-Life Documentation
| State or Territory | Advance Care Directive (Preferences for care) | Advance Care Directive appointment (substitute decision-maker) | Other documentation |
| ACT | Health Direction | Enduring Power of Attorney | Advance care plan Statement of Choices Resuscitation Plan Goals of Care Form Letters from the person |
| NSW | Advance Care Directive (non-statutory) | Enduring Guardian | Statement of Values and Wishes Resuscitation Plan Goals of Care Form Letters from the person |
| NT | Advance Personal Plan Direction under Natural Death Act 1998 (NT) (if made before 17 March 2014) | Advance Personal Plan – Decision Maker | Resuscitation Plan Goals of Care Form Letters from the person |
| QLD | Advance Health Directive | Enduring Power of Attorney for personal matters | Statement of Choices – persons with decision- making capacity Statement of Choices – persons without decision- making capacity Resuscitation Plan Goals of Care Form Letters from the person |
| SA | Advance Care Directive Anticipatory Direction (if made before 30 June 2014) | Advance Care Directive – Substitute Decision Maker Appointment Medical Power of Attorney (if made before June 2014) Enduring Power of Guardianship (if made before 1 June 2014) | Statement of Choices Resuscitation Plan Letters from the person 7 Step Pathway |
| TAS | Advance Care Directive (non-statutory) | Enduring Guardian | Resuscitation Plan Goals of Care Form Letters from the person |
| VIC | Advance Care Directive Refusal of Treatment Certificate (Competent) (if made before 12 March 2018) | Medical treatment Decision Maker Enduring Power of Attorney (Medical Treatment) or attorney (health care decisions) (if made before 12 March 2018) | Statement of Choices Resuscitation Plan Goals of Care Form Letters from the person |
| WA | Advance Health Directive | Enduring Guardian | Statement of Choices Resuscitation Plan Goals of Care Form Letters from the person |
Other types of ACP documentation may not meet the formalities or capacity requirements to be legally binding but may still inform care. These include:
- personally written letters
- letters or documents written by a medical practitioner outlining the person’s preferences, resuscitation status, or whether they should be transferred to
6. Related Documents
5.1 Internal
- Service Delivery Policy
- Advance Care Planning Procedure
- Clinical Governance framework
- Model of Care
- Dignity of Risk and Duty of Care Procedure
- Consent Procedure
- Privacy Policy
- Diversity and Inclusion Procedure
- End of Life Care Procedure
5.2 External
- Aged Care Act 1997
- Consent to Medical Treatment and Palliative Care Act 1995
- Aged Care Quality and Safety Commission (Dec 2019) Guidance and Resources for Providers to support the Aged Care Quality Standards
- Home Care Packages Program Operational Manual
- Advance care planning in aged care: A guide to support implementation in community and residential settings
- End of life law in Australia: An overview for the aged care sector eldac.com.au (accessed 30/4/20)
- National Palliative Care Standards 5th Edition https://palliativecare.org.au/standards (accessed 30/4/20)
- Australian Commission on Safety and Quality in Health Care National Consensus Statement: Essential elements for safe and high-quality end-of-life care https://www.safetyandquality.gov.au/publications-and-resources/resource-library/national- consensus-statement-essential-elements-safe-and-high-quality-end-life-care (accessed 30/4/20)
- Nursing and Midwifery Board of Australia and Australian College of (2002) Code of Ethics for Nurses in Australia
- Health Practitioner Regulation National Law Act (2018)
- Home Care Packages program operational manual a guide for home care providers March 2021
- Aged Care Quality Standards
- Aged Care Quality and Safety Commission Act 2018
- Aged Care Quality and Safety Commission Rules 2018
- Advanced Care Planning: Aged Care Implementation Guide; 2021
- User Rights Principles 2014
- Quality of Care Principles 2014
- Aged Care Quality and Safety Commission Rules 2018
- Charter of Aged Care Rights
- Privacy Act 1988
- Australian Privacy Principles 2014
- Voluntary Assisted Dying Act 2019 and Advance care planning each State and territory legislation and/or policy
7. Document History
Reviewed by: Clinical and Risk Specialist Authorised by: CEO
Date Adopted: July 2022
Next Review Due: September 2025
Version Control
| Version | Date | Change |
| 1 | 21/6/22 | New |
- Aged Care Quality and Safety Commission Guidance and Resources for Providers to support the Aged Care Quality Standards
- Aged Care Quality and Safety Commission Guidance and Resources for Providers to support the Aged Care Quality Australian Government