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Advance care planning and goals of care

Residents & families GPs & clinicians Aged care staff 9 min read

By Dr Josh Hatch, FRACGP

Advance care planning is a set of conversations about what matters to a person, what treatment they would and would not want, and who should speak for them if they cannot speak for themselves. The documents that come out of those conversations, and the rules about who decides, differ between Queensland and New South Wales 811.

Numbers in the text link to the 10 sources listed at the foot of this page.

Does planning make a difference?

The best-known trial is Australian. At a Melbourne university hospital, 309 medical inpatients aged 80 or more were randomised to usual care or usual care plus facilitated advance care planning. Of the 56 who died within six months, their wishes were known and followed for 86% in the planning group and 30% in the usual care group. Relatives of those who died in the planning group had less stress, anxiety and depression 4. It was a single-centre hospital trial, not a trial in aged care 4.

Trials in nursing homes have had mixed results. In Ontario, a program that educated staff, residents and families and offered every resident an advance directive led to fewer hospital admissions and lower costs, with no change in satisfaction or deaths. Only six homes took part 6. A much larger US trial in 360 nursing homes, which offered residents short planning videos, did not reduce hospital transfers or burdensome treatment. Only about one in five eligible residents were recorded as having watched a video 7.

The evidence

Graded on randomised evidence for outcomes that matter: whether wishes are followed, family wellbeing, hospital transfer and burdensome treatment.

Facilitated advance care planning with a trained facilitator

Promising, not yet proven

In one Australian trial, wishes were far more often known and followed, and bereaved families were less distressed.

The evidence

Wishes known and followed in 25 of 29 deaths with planning against 8 of 27 without; relatives had less stress, anxiety and depression, and satisfaction was higher 4.

In practice

Single-centre trial in hospital inpatients aged 80 or more. It has not been repeated in Australian residential aged care 4.

A structured advance directive program across a nursing home

Promising, not yet proven

Fewer hospital admissions and lower costs, without lower satisfaction or more deaths.

The evidence

In 1,292 residents of six Ontario nursing homes, intervention homes had 0.27 hospital admissions per resident against 0.48 in control homes over 18 months. Deaths were similar, 24% against 28% 6.

In practice

Only six homes, pair-matched, with one home per pair randomised, in the late 1990s 6.

Advance care planning videos offered by nursing home staff

Not supported

No reduction in hospital transfers, burdensome treatment or use of hospice in a large pragmatic trial.

The evidence

In 360 US nursing homes, hospital transfers per 1,000 days were 3.7 with the video program and 3.9 without, a difference that was not significant 7. A later post hoc analysis of residents who died found a small reduction, 1.7 percentage points, in transfers in the last 90 days of life 17.

In practice

Fidelity was low: about 22% of eligible residents with advanced illness were recorded as viewing a video 7. The post hoc finding is weaker evidence than the main result 17.

Queensland: the documents

Queensland law and Queensland Health guidance, as at the review date. These details change.

  • Advance Health Directive. In Queensland, an Advance Health Directive is made under the Powers of Attorney Act 1998 (Qld) and is legally binding 810. It must be in writing and signed by the person, and signed and dated by a health professional who certifies that the person appeared to have capacity 8. It applies as soon as the person loses capacity 8.

  • Refusing life-sustaining treatment. In Queensland, a direction in an Advance Health Directive to refuse life-sustaining treatment operates only in defined circumstances. One is that the person has a terminal illness or condition that is incurable or irreversible and the treating doctor and another doctor expect death within a year. The person must also have no reasonable prospect of regaining capacity 8.

  • Informal written wishes. Queensland has only statutory advance directives. According to End of Life Law in Australia, the Queensland legislation has removed the legal effect of common law advance directives 8. A letter or note of wishes can still guide decisions, but it does not bind in the way an Advance Health Directive does.

  • Enduring Power of Attorney. Appoints one or more people to make decisions for health matters, financial matters or both. It is legally binding 10.

  • Statement of Choices. Records a person’s views to guide substitute decision-makers and clinicians. It is not legally binding, but it can guide clinical care 10.

  • Who decides if there is no direction. In Queensland the order is: a direction in an Advance Health Directive; a guardian appointed by the Queensland Civil and Administrative Tribunal; an attorney appointed under an Enduring Power of Attorney or Advance Health Directive; a statutory health attorney, being the spouse or partner, then an unpaid carer, then a close friend or relation; and finally the Public Guardian 9.

New South Wales: the documents

New South Wales law and NSW Health guidance, as at the review date. These details change.

  • Advance Care Directive. In New South Wales, NSW Health describes an Advance Care Directive as legally binding. It can be spoken or written, and it does not need to be signed or witnessed to be valid. NSW Health provides a form for recording wishes 11.

  • When a directive applies. In New South Wales, a valid advance care directive made at common law must be followed. A substitute decision-maker is not needed for that decision, although they may help interpret it 12.

  • Enduring guardian. A person appointed with the right to consent to medical and dental treatment on the person’s behalf 11.

  • Person responsible. Under the Guardianship Act 1987 (NSW), the order is: an appointed guardian or enduring guardian; a spouse, de facto spouse or partner in a close, continuing relationship; an unpaid carer who regularly provides or arranges domestic support; and an unpaid friend or relative with a close personal relationship and frequent contact 1112.

  • Disputes. In New South Wales, any interested person, including a health professional, can apply to the NSW Civil and Administrative Tribunal to review a substitute decision-maker’s appointment or to seek consent to treatment. The Supreme Court can also hear disputes about end-of-life treatment 12.

  • Keeping it findable. NSW Health recommends uploading a completed Advance Care Directive to My Health Record and leaving copies with the person responsible, family or carer, doctor and care facility 11.

Goals of care, not just documents

A document records a conversation at one point in time. Health changes, and so do wishes. The Quality Standards require providers to support residents, families and substitute decision-makers to keep having end-of-life planning conversations, to discuss requesting or declining personal care, life-prolonging treatment and treatment of reversible acute problems, and to review advance care planning documents so they match current needs, goals and preferences 3.

Useful goals-of-care discussions are specific. They cover what the person would want if they had a chest infection, a fall with an injury, a stroke, or a sudden collapse, and where they would want to be cared for. They also name who will speak for the person and how to reach them.

Some residents have documents made in the other state. This page does not cover whether a document made in one state is recognised in the other. If documents were made interstate, check with the guardianship body in the state where care is being given, or with a lawyer.

Related pages on this site

Sources cited on this page

  1. 3 Australian Government Department of Health, Disability and Ageing. Strengthened Aged Care Quality Standards (November 2025; implemented 1 November 2025). Outcome 5.7 Palliative care and end-of-life care, Actions 5.7.1 to 5.7.4. View source
  2. 4 Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345. (Single centre, Melbourne university hospital; 309 medical inpatients aged 80 or more.) View source
  3. 6 Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA. 2000;283:1437–44. (Six Ontario nursing homes, pair-matched, one home per pair randomised.) View source
  4. 7 Mitchell SL, Volandes AE, Gutman R, et al. Advance care planning video intervention among long-stay nursing home residents: a pragmatic cluster randomized clinical trial (PROVEN). JAMA Intern Med. 2020;180:1070–8. (360 US nursing homes.) View source
  5. 8 End of Life Law for Clinicians / End of Life Law in Australia, Australian Centre for Health Law Research, Queensland University of Technology. Advance directives: Queensland. (Accessed October 2026; page undated.) View source
  6. 9 End of Life Law in Australia, Queensland University of Technology. Stopping treatment, adults: Queensland. (Accessed October 2026; page undated.) View source
  7. 10 Queensland Health. Queensland advance care planning documents: summary. Version 2.0, January 2025. View source
  8. 11 NSW Health. Advance care planning. (Current as at 26 August 2025.) View source
  9. 12 End of Life Law in Australia, Queensland University of Technology. Stopping treatment, adults: New South Wales. (Accessed October 2026; page undated.) View source
  10. 17 Moyo P, Loomer L, Teno JM, et al. Effect of a video-assisted advance care planning intervention on end-of-life health care transitions among long-stay nursing home residents. J Am Med Dir Assoc. 2022;23:394–8. (Post hoc analysis of the PROVEN trial.) View source

See every source cited across the palliative and end-of-life care section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at October 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. It is not legal advice. Evidence, Australian regulatory requirements and state laws on advance care planning, substitute decision-making and voluntary assisted dying change — always confirm current advice with the treating GP, the state health department or a lawyer.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

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