Advance Care Planning Support Guide Staff

Advance care planning (ACP) is a cornerstone of person-centred aged care — giving consumers a voice in their own care even when they can no longer speak for themselves. This guide helps staff understand their role in the ACP process, facilitate planning conversations, and ensure that directives are documented, accessible and honoured.

Published

May 29, 2026

Advance Care Planning Support Guide for Aged Care Staff

Advance care planning (ACP) empowers consumers to document their values, preferences and decisions about future care — ensuring their voice is heard even when they can no longer communicate directly. For aged care providers, facilitating and honouring ACP is both a Standard 1 obligation and a fundamental act of respect. This guide walks your team through the ACP process from first conversation to documentation to review.

What This Guide Covers

What advance care planning is and why it matters in aged care
Legal frameworks — advance care directives, enduring guardianship and power of attorney
Who is a Substitute Decision-Maker (SDM) and when they are involved
Initiating ACP conversations — timing, language and approach
Documenting ACP outcomes in the care record
Reviewing and updating ACP as health status changes
State and territory differences in ACP legislation
When ACP conflicts with family wishes — how to navigate

Key Learning Outcomes

Explain what advance care planning is and the documents that form part of it
Identify the consumer's Substitute Decision-Maker and understand their authority
Facilitate a respectful ACP conversation appropriate to the consumer's capacity
Ensure ACP documentation is accurately recorded and accessible to the care team
Recognise when ACP should be reviewed and initiate that process

Who Should Complete This Training

Registered Nurses, clinical leads, care managers and any staff involved in care planning conversations. PCAs should have a working understanding of ACP and know how to escalate ACP questions to clinical staff.

Alignment to the Strengthened Aged Care Quality Standards

Directly relevant to Standard 1 (The Person) — the right to make decisions about one's own care — and Standard 4 (Care and Support), which requires care plans to reflect the consumer's goals, preferences and advance care wishes.

Make ACP Documents Accessible Across Your Team

Governa helps aged care teams ensure advance care plans are linked to resident records and accessible to the right staff at the point of care. Ask Norma to surface your ACP policy in seconds.

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