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Development and evaluation of an aged care specific Advance Care Plan
  1. William Silvester1,
  2. Ruth A Parslow2,
  3. Virginia J Lewis2,
  4. Rachael S Fullam1,
  5. Rebekah Sjanta1,
  6. Lynne Jackson1,
  7. Vanessa White2 and
  8. Rosalie Hudson3
  1. 1Respecting Patient Choices, Austin Health, Heidelberg, Victoria, Australia
  2. 2Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, Victoria, Australia
  3. 3School of Nursing and Social Work, University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Associate Professor William Silvester, Respecting Patient Choices, Austin Hospital, PO Box 5555, Heidelberg, VIC 3084, Australia; william.SILVESTER{at}


Objectives To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention.

Design An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention.

Participants and setting 19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria.

Results Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans.

Conclusions Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

  • End-of-life
  • Terminal Care
  • Advance Care Planning
  • Advance Directives
  • Nursing Homes
  • Aged Care

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