For Residential
Aged Care

An Advance Care Plan is a document that sets out any medical treatment you do or do not consent to – in advance, to be relied on only in the event you lose decision-making capacity.

An Advance Care Plan can also set out your values. That is, those things that are important to you (and which may influence your choices) – such as being able to communicate with your loved ones. Setting out your values can help inform your doctors, carers and substitute decision-makers about what treatment you would or would not have consented to.

If one day you lose decision-making capacity, an Advance Care Plan can assist those involved with your care to make treatment decisions on your behalf by informing them of your wishes. It is therefore important you share your Advance Care Plan with others so it is readily available in the event you lose capacity (which can happen suddenly and unexpectedly, such as in the case of a head injury).

Your Advance Care Plan can inform your family and doctors what specific treatments you do and do not want. It can also inform them what your values are, so they can be guided in deciding what treatment you would or would not have wanted (if such treatment is not specified in your Advance Care Plan). An Advance Care Plan will assist your family or doctors in making decisions about your medical treatment that are in line with your preferences in the event you cannot speak for yourself.

An ‘Advance Care Plan’ is separate and distinct from a document prepared by health practitioners to plan your care, which is often referred to as a ‘Care Plan’. An Advance Care Plan is not to be confused with a Care Plan (which should include an Advance Care Plan).

While a Care Plan should be prepared taking your preferences into account (particularly if you are in aged care), it is not an Advance Care Plan. An Advance Care Plan can only be completed by you, and sets out your choices only. It does not include an assessment of your needs, which a Care Plan does. While an Advance Care Plan may be completed with support from health practitioners, it cannot be completed by them.

Yes.

A Touchstone Life Care Advance Care Plan is:

• Legally valid as a Common Law Advance Care Directive in every state.
• A legally valid expression of your wishes.
• Must be considered by health professionals when making decisions about you.
• An expression of your consent or your refusal of consent to medical care.

The idea of advance care directives or advance care plans has been around for a long time.

No matter whether you call it an Advance Care Directive or an Advance Care Plans they are a valid expression of a person’s consent or of their refusal of consent, in advance of incapacity.

Incapacity means you have lost the capacity to make or speak your decisions or wishes.

Your advance care directive or plan can only be used to make decisions about your care when you cannot- ie when you lose capacity.

Health practitioners are obliged to consider any expression of a person’s wishes for medical care.

They cannot ignore an expression of consent or refusal of consent no matter what form is used.

Touchstone Life Care’s Advance Care Plans are not the same as a Statutory directive, which are different in every state, (and do not exist at all in NSW and Tasmania) These have a variety of names; some are called Health Care Directives, others a State Advance Care Directive or Personal Statement of Health.

Any person who is trusted by their client can help them complete an Advance Care Plan.

In fact many professionals are required to offer advance care planning as part of a wholistic aged care advisory service, or as a government supported aged care provider.

Trusted advisers, social workers, nurses or doctors are commonly asked by people to assist them in their estate planning or end of life planning.

Any of these people can help someone prepare an advance care plan. However they must not lead their client in any way.

Many professionals do not feel confident about all of the legal, family, social, spiritual and medical aspects of advance care planning. That is why Touchstone Life Care has an INTEROPERABLE planning system. This means you can assist your patient or client to think about, or start their plan, and recommend they share it with other trusted contacts or advisers to get answers to questions that might arise.

A Touchstone Life Care plan can be started by an estate planner and the client can be helped to complete it by their GP- or vice versa.

You should emphasise to your client that they should make their decisions without being coerced in any way, and they should demonstrate that they have capacity to make these decisions and understand the consequences of their decisions.

Touchstone Life Care’s unique automated sharing system grants additional legal validity to these plans because their trusted contacts can see, read and discuss the plan ahead of time, thereby vouching that it was prepared without coercion, that the person making it had capacity at the time. Or, if there is any doubt about the plan they can contact the person who made it, or the other contacts listed to discuss their concerns about it.

The Aged Care Quality Standards require that you as a provider or practitioner are clear on what your patient or clients’ wishes are, and that the person’s choices form the core of your treatment and care planning for them. You have to “provide examples of actions and evidence of how your assessment and planning identifies and addresses the consumer’s needs, goals and preferences, including advance care planning.” In addition, your organisation needs to have workforce training in place so that “in day-to-day interactions with consumers, the workforce is expected to treat each consumer as an individual with their own unique life experiences, preferences, needs and abilities.” (Standard 7) Touchstone Life Care for Providers addresses many of your requirements for these and other Aged Care Quality Standards including Standards 1,2,3, and 8, all with a single click to  download or a link to the software. If you would like training for your staff about how to have conversations about their needs, goals, and preferences, you can learn more at our TLC Institute or contact us.

An Advance Care Plan will not cover all treatments – only the ones you specify. It is important to as clear and specific as possible about what treatments you do and do not want.

An Advance Care Plan also cannot compel a health practitioner to withhold palliative care, assist you to die, or give you treatment which is futile.

Since it is not possible to cover every conceivable treatment in an Advance Care Plan, Touchstone’s Advance Care Plan allows you to set out what is important to you, and the things you need to live your minimum quality of life – such as being able to communicate with your loved ones. These values will guide health practitioners when treating you by enabling them to assess whether you would have consented to particular treatment in a given circumstance. For example, if life-saving brain surgery would inevitably leave you non-communicative (eg. in a permanent vegetative state) and you have indicated you do not want to live this way, your doctors might decide against performing such surgery.

Note that setting out your values alone (without being specific about treatment) will be open to interpretation. In the example given, a decision to operate could be made if it is believed you might be able to communicate with assistance, and therefore would have consented on the basis of your values.

Therefore if there is treatment you absolutely want to exclude, you must be very specific about that in your Advance Care Plan. The more specific and clear about the treatment you consent or refuse consent to, the greater likelihood you wishes will be followed.

An Advance Care Plan is a document which sets out your wishes in relation to medical care. It expresses your consent, or refusal or consent in advance. Unlike powers of attorney or guardianship, an Advance Care Plan in itself does not empower another person to make a decision for you.

A person who makes medical treatment decisions on your behalf, if you lose decision-making capacity, is generally referred to as a substitute decision maker. A substitute decision maker must have regard to your wishes, including those set out in your Advance Care Plan. This is because a substitute decision maker must decide your medical treatment in accordance with what they believe you would have wanted (and not in accordance with what they believe your best interests are).

Every state and territory in Australia has different laws around powers of attorney and guardianship. Depending on your state or territory and individual circumstances, your substitute decision-maker might be your power of attorney, or a guardian.