Understanding advance care planning

When providing care for ageing individuals, it is valuable to understand how the approach to care may need to be re-evaluated and updated over time. This may be due to a person’s health and their requirements evolving, or it could be dependent on their individual values and preferences.

An important element of the work undertaken by aged care professionals, is the focus around empowering seniors and making sure they are living life on their terms as much as possible.

This is where advance care planning is an important consideration; to offer ethical, legal and practical guidelines for aged care workers and medical staff to follow in continuing to deliver the best care possible to ageing Australians.

What is advance care planning?

Advance care planning refers to the process of making a plan for health and personal care which may be needed in the future. It is usually undertaken by an ageing individual, along with advice from their family and health professionals. The plan is a way for a person to ensure that their own preferences and values continue to be recognised in the delivery of care, even at a time when they may no longer have the capacity to make decisions for themselves.

The components included in advance care plan may include:

• The person explaining their preferences for future health care
• The person appointing a substitute decision-maker for if/when needed
• Documenting the person’s preferences in a legally-binding document (such as an Advance Care Directive)

Advance care planning is not the same as an Advance Care Directive. While an advance care plan informs a person’s loved ones and caregivers about their values and preferences for their health care and is ideally documented, it is not a formal legally-binding plan. To ensure that wishes will be upheld, an Advance Care Directive must be created. This is sometimes known as a living will and is legally-binding.

It’s worth noting that the conversations and documentation around advance care planning aren’t a one-time occurrence and should be revisited at various intervals, especially when a person’s health situation is shifting.

Advance care planning that upholds national quality standards

During advance care planning processes, Australian national quality standards must be adhered to. These standards are designed to underpin high quality aged care and protect people from harm.

Aged care professionals and services must promote compliance with these standards, and systems and procedures in services should reflect this understanding and appreciation for the importance of advance care planning.

As an aged care worker, whether you are employed in residential aged care or community-based care, you should strive to incorporate the following when having advance care planning conversations:

• Be aware of whether a person has an Advance Care Directive or plan
• Promote the person’s involvement in their advance care planning if they have the capacity to do so
• Ensure a person has a substitute decision-maker and ascertain whether they are legally appointed
• Document all advance care planning information and record it
• Ensure a person’s advance care plan or legal care directive is being upheld

Supporting staff with advance care planning

It’s vital that aged care teams are on the same page when it comes to understanding advance care planning, but also implementing it.

While the resident along with their family and sometimes medical professionals creates the advance care plan, aged care staff can encourage the conversations, store documents and follow the directions of plans when the time comes to action the plan.

By educating the staff within your aged care service, they can better understand their role and be confident to have appropriate conversations with those in their care pertaining to advance care planning.

To support aged care professionals, incorporate advance care planning education into staff meetings and workshops. Focus on these key points to empower aged care workers to broach advance care planning discussions and provide care that reflects each individual’s values and preferences now and in the future.

Key advance care planning education areas

• Clarification on what advance care planning is

With the knowledge and understanding of what advance care planning is, its benefits, the legalities and how to incorporate it into care, aged care staff can be better equipped to empower ageing individuals and provide the highest standard of individualised care. Let aged care teams know what their role is in the advance care planning process. For example, they can initiate and be a part of conversations around advance care planning, but they cannot create the plan for a resident. They should determine whether a person has an advance care plan or directive in place and approach care accordingly.

• Practical guidance on advance care plan conversations

It is generally expected that medical staff or sometimes aged care workers will initiate communication around advance care planning. As such, aged care workers need support around when and how to have these conversations, including appropriate prompts to open dialogue with those in their care and effectively support their residents. Communication should ideally take place early on as a person begins receiving aged care. It should then be revisited at regular intervals or at any time a person’s health status changes. Aged care workers should be educated on identifying an appropriate environment for conversations, using active listening techniques and reading and responding to body language and cues from residents and their family members.

• Incorporating advance care planning into care

Show your aged care staff how someone’s advance care plan may be actioned through real-life examples. Create systems and procedures that mean that advance care planning is integrated with the care your aged care service delivers. Documentation should be stored in a person’s health record and be easily accessible for aged care workers.

• Documentation and legalities

Educate aged care teams on how to document advance care plans and what a legally-binding Aged Care Directive is compared to an advance care plan. Ensure everyone understands what to do when a person is admitted to your aged care setting and has a plan or Advance Care Directive in place. Show your team where and how to store the documentation, and how to enact directives to inform care.

The benefits of advance care planning

Advance care planning benefits everyone involved, including the elderly individual, their family and their carers.

These benefits may include:

• Confidence that a person is going to receive the care they want
• Improved staff satisfaction that their care recipients are receiving the appropriate care
• Reduction in stress for family members making choices on their ageing relatives’ behalf
• Less inappropriate aged care facility transfers to hospitals

Effectively, ensuring a person is going to receive the care they want at every stage of their life offers comfort to the individual and those around them.

Creating a space in your aged care facility for regular, ongoing advance care planning adds to the way you empower the elderly residents in your care. This shouldn’t be separate to the daily care they receive but an integral part of their care plan.

Support ageing individuals and support an aged care sector that prioritises quality care at every stage of life. Learn more about advance care planning here.

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