Introducing ACP Concepts


Advance Care Planning (ACP) involves a person considering and planning for future care. ACP guides decision-making when the person can no longer speak for themselves. It can involve the development of a formal document, an Advance Care Directive (ACD or AD).

Why ACP?

Aims of ACP:
  • To provide guidance for decision-making when a person cannot speak for themselves.
  • To designate a substitute decision-maker (SDM).
  • To complete a written document commonly referred to as an ACD. This document legally recognises the instructions of a competent adult to identify someone whom they trust to speak on their behalf in the future if they cannot make their choices known and/or record instructions about their preferences for future healthcare and lifestyle choices.
ACP is an ongoing process requiring continued review of:
  • Goals of care and preferences for medical treatment.
  • Changes occurring in the older person’s overall health or lifestyle situation.
  • Recognition that plans may vary depending on whether the person is healthy, has mild to moderate chronic illness or is likely to die in the next 6 months.
ACP improves:
  • Compliance by doctors and family members with the person’s values and wishes.
  • Likelihood the person will die in their preferred place.
  • The older person and their family’s satisfaction with care.
  • Family preparedness for what to expect during the dying process.
  • Quality of death as reported by relatives.

Role of Nurses

The ACP Process

Common Law Principles

Substitute Decision-Maker

Competence and Capacity

Dementia and ACP

Medically Indicated Treatment

Other Considerations

ACP - State and Territory Information

It is important to understand and be familiar with the legal responsibilities and implications in your jurisdiction(s).


If the issues are complex or if you would like more information about ACP matters, the Decision Assist Advance Care Planning Advisory Service is available for telephone and e-mail enquiries.

Helpful Resources


Page updated 23 May 2017

palliAGED is funded by the Australian Government Department of Health.