Anticipating and preparing for end of life


Advance Care Planning (ACP) is the process which enables an individual to make plans about future health care to provide direction for healthcare professionals when the individual  is no longer in a 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.

Advance Care Planning Australia provides training and education for aged care workers to improve their knowledge and confidence when having advance care planning conversations. There are a range of online courses, workshops, webinars and information sessions on advance care planning to help you strengthen the skills of your workforce.


When residents are no longer appropriate for curative treatment, Goals of Care can help to ensure that they receive appropriate intervention and are not subjected to burdensome or futile treatments.Goals of Care are a way of describing what medical treatments a person will receive incorporating the resident’s wishes and preferences.

Goals of care should be documented by the resident’s medical specialist or General Practitioner in consultation with the resident and their family. They are informed by open, honest and realistic discussion around end of life care and should be reviewed and updated as the resident’s status changes.

Conducting a family meeting can be a useful way to provide information in response to a family’s questions and concerns and to establish Goals of Care.

This trajectory graph below provides guidance on when to establish and review Goals of Care.  Early identification of deterioration and regular review of Goals of Care supports a peaceful and dignified death. 


Preparing and anticipating end of life for Aged Care residents

Useful links providing more information about Goals of Care include:


Family 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
  • Conflict is identified between the family and the treating team

Here is a helpful link.


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

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

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