Table 1

Principles for Advance Care Planning

Overarching statement:
The purpose of advance care planning (ACP) is to aid decision-making if the older person loses capacity. Where the older person has capacity for decision-making their current views take precedence over the ACP document. The ACP is used only when the older person is unable to communicate their wishes regarding medical treatments.
1	Policies. Written policies about ACP should be readily accessible in every residential aged care service (RACS). Policies should include the systems needed to establish ACP as a routine component of care, all aspects of documentation, including where the ACP is to be kept, how many copies, when to be reviewed, etc.
2	Education. Education about ACP should be regularly provided to all RAC staff and GPs.
3	Information in RACS. Information about ACP is best provided to residents and families before admission (eg, included in information brochure); followed by well planned individual discussions as soon as practicable after admission—normally within 28 days unless there are unforeseen circumstances.
4	Routinely administered and reviewed: ACP should be incorporated into routine clinical decision making and care planning, regularly reviewed, particularly when circumstances change (eg, exacerbation of illness, health deterioration or hospital admission), or at least annually.
5	Voluntariness. While the aim of ACP is to involve every older person in the discussion, no one should be coerced and everyone is free to change their ACP at any time.
6	Communication is the key. ACP should be accompanied by full discussion with the older person and/or family, in private, and initiated by a health professional with relevant skills in this area. ACP forms should not be sent via mail without the corresponding personal discussion.
7	Older persons’ best interests. The older person's treatment should be directed towards their best interests, informed by (a), the competent person's current wishes, (b) the non-competent person's previously expressed wishes, or (c) family's views regarding the older persons’ wishes. In every case, decisions should be fully supported by appropriate information.
8	The older person with dementia. Every person with dementia should be deemed competent unless deemed incompetent by the relevant medical officer. People with dementia may be able to take part in some aspects of ACP even if they lack competence to complete a legal document.
9	Inevitability of death. Most people requiring aged care services have at least one and, in many cases, several life-threatening, incurable illnesses leading to inevitable death. ACP discussions should therefore promote frank discussion of death and dying.
10	End of life. Older persons and their families should be informed about the principles of end-of-life care, namely that this (a) does not mean ‘no treatment’; (b) is offered well before death is imminent; (c) neither hastens death nor unduly prolongs life; and (d) is delivered by all doctors and nurses with assistance from specialist services as required.
11	Treatment options. The focus of the conversation is on reasonable outcomes and ‘living well’—it should raise the issues of life-prolonging treatment generally and not focus on any specific treatment.
12	Family's role. Families are encouraged to participate in all aspects of the older person's care planning. The family should comply with what is in the older person's best interest even if this is not congruent with their own views.
13	GP involvement. Best practice is for the GP to be included in ACP discussions. A copy of the (current) ACP should be forwarded to the older person's GP.
14	Confidentiality. The older person and/or family should be informed about confidentiality and safekeeping of their documented wishes. Information will only be provided to health professionals as required.
15	ACP and enduring power of attorney. ACP complements any legally binding power of attorney document.
16	Information transfer: Effective systems to support transfer of information (ie, copies of completed ACP-related documents) to the older persons’ medical records, GP, family and local health services are paramount.
17	Documentation: ACP documents should clearly specify (at a minimum) (a) nominated substitute decision maker (and contact details) where applicable, (b) resident competency at the time of completion (c) current state of health, (c) values and beliefs (things that matter most in life), (d) future unacceptable health conditions, (e) specification of resident preferences in relation to life-prolonging treatment and hospital transfer, (f) specific wanted/unwanted treatments—where applicable, (g) goals for end-of-life care, (h) appropriate signatures (clear, complete, dated, witnessed) and include evidence of GP review.