My Wishes
Advance Care Planning Program

Residential aged care staff


Advance care planning (ACP) can have many benefits within the residential aged care (nursing home or hostel) setting. It can make it easier for residents and their family to discuss prognosis and possible future treatment choices. By doing this it improves communication between the resident, their family, the staff and their treating General Practitioner. It means that difficult decisions about care do not have to be made at the last minute and with no preparation. It also increases the likelihood that the resident’s values and wishes will be known and followed in treatment and care decisions.

ACP occurs to a greater or lesser extent in all aged care facilities, although the majority of facilities do not take a particularly active or systematic approach. The range of approaches taken by facilities has been described under a continuum model of practice which is explained here.
The My Wishes program believes that there is considerable scope for aged care facilities to take a more consistent and systematic approach to ACP. Below you will find a number of resources that have been developed or adapted as part of the My Wishes program to help facilities review their current practice and move toward a more systematic approach.
A one-page leaflet introducing the concept of ACP and some of its benefits. This is suitable for general distribution – such as information packs for residential care facilities, as well as GP surgeries, community organisations or hospitals.
A four-page brochure that provides an introduction to many of the issues involved in ACP relevant to staff of residential aged care facilities.
A four-page brochure that provides a general introduction to many of the issues involved in ACP. This may be suitable for residential aged care staff or GPs to give to residents or family as part of discussions about the resident’s ongoing care within the facility.
A four-page brochure that provides an introduction to many of the issues involved in ACP tailored to the needs of GPs. This may be useful for residential aged care staff to give to GPs associated with their facility.
A model that explains the range of practices that facilities may take in terms of how routinely and systematically they approach ACP. It can be used as a quality improvement tool to help facility managers understand their current practice and look at possible areas for improvement.
A comprehensive outline to assist staff in setting up and conducting ACP discussions. It takes the reader through each step in the process, identifies key issues and provides possible questions or prompts. The guidelines can be a used as a training tool or reference for staff involved in ACP.
Outlines four broad areas of competence for staff related to ACP: explain the nature and benefits of ACP; initiate and manage ACP discussions; follow-up outcomes from ACP discussions; and take responsibility for maintaining ACP systems.
A flowchart to provide guidance to staff on how to include ACP in the assessment of unwell residents. It was developed as part of a specific program called the Aged Care Triage (ACT) but can be used by any residential aged care service.
A one-page overview of strategies and systems that aged care facilities can use to set up and maintain an ACP program.
A comprehensive audit tool for aged care facilities that want to develop a more systematic approach to ACP. It takes the facility through a number of questions with recommended actions depending on the outcomes to each question.
This page outlines some key issues about documenting your wishes and has forms developed as part of the My Wishes program.
Information sheets related to chronic and end-of-life care
Documents that provide information that might help patients or their family understand the progression of chronic disease and end-of-life care. It is recommended that these information sheets be given to patients or family as part of a discussion with them rather than being distributed in isolation
To get more detailed information about issues such as Power of Attorney, Enduring Guardianship, substitute decision making and other ACP programs, go to Further Information
© 2016 South Western Sydney Local Health District
Last Updated: 03 July, 2013
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