Anticipating and preparing for end of life


Advance Care Planning (ACP) is the process which enables individuals to make plans about future health care to provide direction for healthcare professionals when a person is not in the position to make and/or communicate their own choices. General practitioners and aged care teams play a key role in Advance Care Planning so it’s important for them to have a good understanding of what advance care planning is and what’s involved in the advance care planning process.

Here is the link to Advance Care Planning Australia.

Training and education is the best way for aged care workers to improve their knowledge and confidence to have advance care planning conversations. There are a range of online courses, workshops, webinars and information sessions on advance care planning.

Here is the link to help you strengthen the skills of your workforce.


Whereas an advance care directive provides information about the person’s preferences, Goals of Care are a way of describing what medical treatments a person will receive.

Goals of Care should incorporate the wishes and preferences of the person. There should be open, honest and realistic discussion around end of life care to inform the Goals of Care. These should be reviewed and documented by the resident’s medical specialist or General Practitioner in consultation with the resident and their family.

A Goal of Care plan helps to ensure that residents, who are unlikely to benefit from medical treatment aimed at cure, receive care appropriate to their condition and are not subjected to burdensome or futile treatments.

Conducting a family meeting can be useful to provide information, to address the family’s questions and concerns, and to establish Goals of Care.

Useful links about Goals of Care:

Early identification of deterioration and regular review of goals of care supports a peaceful dignified death.


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These meetings are invaluable. Consider conducting these meetings when:

  • Confirming disease progression
  • Discontinuing treatment or when maximal medical management has been reached
  • Discharge is planned from an inpatient setting
  • The resident’s condition changes, and goals of care need re-assessing
  • Referring to palliative care

Here is a helpful  link:


Goals of Care can be communicated using ISBAR to support handover. Using a standardised format can assist the transfer of information.

ISBAR (Introduction/ Identify, Situation, Background Assessment, Recommendation) is an effective tool to  support clinical handover of a resident.

ISBAR organises a conversation into the essential elements in the transfer of information from one source to another. Effective communication lies at the very heart of good care for residents.

Information about ISBAR can be found courtesy of the Western NSW PHN