Background Decision-making at the end-of-life is complex and requires significant resources despite the presence of advance care plans. Questions often arise as to the meaning of an advance care plan, what constitutes such a plan and its legal status.

Aims This study aimed to examine issues influencing the decisions of people with advanced medical conditions.

Methods Case study methodology was used to inform the design of the study in two phases. Firstly, chart audits informed development of cases discussed in interviews. A purposive sample (n=20) with experience in advance care planning at end-of-life including health professionals, community leaders, patients and carers were interviewed. The study was conducted in a metropolitan health service.

Results Results indicate that advance care planning takes place in decision-making moments. The readiness of those involved in decision-making to either commence planning for end-of-life care or to implement a plan at end-of-life to provide for care needs were factors. End-of-life care planning and action occur in a context of difference (people, place and tensions).

Discussion and Conclusions This study suggests that, whether advance directives are available or not, towards the end of a patient's life, clinical decision-making is often in response to issues that may not have been predicted or discussed in the planning phase. Health professionals and family members may be ill-equipped to engage in discussions, despite the presence of an advance care plan. Policy, education and resources need to support the necessity for in the moment decision-making.

Acknowledgement This project was funded by the National Health and Medical Research Council of Australia Palliative Care Program Grant.