SLHD My Wishes
Advance Care Planning

Residential Aged Care Staff (RACF)

Advance Care Planning can have many benefits for people in Residential Aged Care Facilities (RACF). It can make it easier for residents and their family to discuss prognosis and possible healthcare choices. By doing this it makes it improves communication between the resident and their family, the staff and their doctors. It means that clinical 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 the treatment and care decisions.

Triggers for RACF staff to start the conversation:

  • The initial meeting with the resident and their Person Responsible (legal substitute decision maker). Conversations should be routine; it doesn’t mean the resident is expected to die.
  • Early cognitive impairment.
  • Frequent resident hospital admissions.
  • New diagnosis of chronic or life limiting disease.
  • Family or resident request for discussion.

A case conference that includes the resident and their Person Responsible is the best place for ACP discussions

Resident's Documentation

  1. Identify whether a resident has capacity to make their own care decisions or whether these have to be made by the Person Responsible. Capacity means that the resident can understand the facts and choices involved, weigh up the consequences and communicate their decision.

    If the resident has capacity:

  • Help them identify who their Person Responsible would be and whether they need to formally appoint someone in this role as an Enduring Guardian.
  • Support the resident and their Person Responsible to discuss their current health problems and likely treatment choices into the future with their treating doctor. Include discussions about their values and wishes about their end-of-life care.
  • Document decisions on an Advance Care Directive (ACD).

    If the resident does not have capacity:

  • Encourage the Person Responsible to consider what the resident’s values and wishes would be related to their end-of-life care. Include the treating doctor in treatment decisions. Include the resident as much as they are wanting to be involved.
  • Document decisions on an Advance Care Plan (ACP).
  1. Ensure all documentation is maintained in a prominent way in the person’s medical record.
  2. Submit documentation to their local SLHD facility to be included in their electronic medicalĀ  record
  3. Ensure that documentation is referred to and used in any care planning and treatment decisions for the person in the future.
  4. Ensure that documentation accompanies residents who need to be transferred to hospital.
  5. Consider submitting a NSW Palliative Ambulance Plan

Staff Responsibilities

Advance Care Planning has not been developed as the role of one particular group of healthcare staff. There are several levels of responsibility.

All staff with a direct caring role for patients and resident-related administrative staff should:

  • understand what Advance Care Planning is;
  • be able to explain Advance Care Planning to resident in general terms;
  • be able to locate and provide information to residents and family;
  • be able to recognise and manage Advance Care Planning documents within the resident’s medical records system.

Senior care staff and treating doctors should be able to do all the above, as well as:

  • initiate and facilitate discussions with a resident and/or their Person Responsible.
  • fully document outcomes of Advance Care Planning discussions in the relevant format for their own facility;
  • take responsibility for knowing if a resident has an ACD or an ACP
  • ensuring any ACD or ACP is referred to and used in any subsequent care planning.