Making an advance care plan

  • You may have a person in your life that no longer has the capacity to make their own decisions about their care and you may be their legal substitute decision-maker.
  • This may be because:
    • they legally appointed you when they still had capacity
    • you have been appointed by a guardianship authority, or
    • you are someone that is considered by law to have a close and ongoing relationship with the person (this is normally a spouse, a close relative or an unpaid carer).

Benefits of an advance care plan

  • Making an advance care plan for someone has several benefits.
    • It allows those who are close to the person to reflect on any conversations or comments the person may have made about their values and attitudes towards their care near the end of life.
    • It will help you prepare for possible decisions you may have to make about the person’s care, rather than having to make decisions at a time of crisis without any preparation.
  • It does not lock you into specific decisions now that will automatically be followed later. Rather, it gives you a chance to consider issues and make statements that can be used to guide treatment decisions at the time they have to be made.

Before making an advance care plan

  • Before making an advance care plan, you must find out if the person has expressed their wishes through any written or verbal instructions and you must follow these as part of the advance care plan. Apart from formal documents, this might include letters, diaries or emails to friends or family members.
  • Even if the person is considered to not have legal capacity, you should still try to gauge their feelings and consider these as part of your decisions.
  • If they have not left any clear instructions, you could consult with other family members or friends with whom the person might have discussed their wishes. You might think about previous decisions they have made in their life and how they made these. This will allow you to make a plan that reflects the person’s wishes as much as possible.
  • If you cannot work out what the person would have chosen, you will need to weigh up the pros and cons of each course of action and decide what is in their best interests.

How to make an advance care plan

  • You would normally make an advance care plan with the support and input of healthcare staff who are looking after the person – such as their GP, staff of an aged care facility or a community agency providing care at home.
  • The Worksheet in this website, Advance care plan for someone that has lost capacity is one example of an advance care plan you could use.
  • We recommend that you print out a blank form and use it for discussion with close friends and family or healthcare staff. After getting their input as appropriate, you can complete the form online or save a version to your computer and complete this version. The final version of the document should be given to the person’s GP and any residential or healthcare staff looking after the person.

Two other State-based examples of such documents are:

  • A Plan of Care from the Advance Care Directives Association for New South Wales
  • Statement of Choices (Victoria) for the non-competent person(link is external) from Respecting Patient Choices