Guidelines for a Palliative Approach in Residential Aged Care

to commence discussions before or at the time of admission and to review the advance care plan
document several times to ensure that it is comprehensive. Although it is preferable that such
discussions take place with the resident’s GP before admission, this can still be done as soon as
practical after admission.
If the resident cannot manage a great deal of decision-making in one sitting, it is still possible to
determine their basic values and wishes immediately. For example, it may be possible to determine
whether the resident wants life-sustaining treatment and under what conditions, and whether they
want to be transferred to hospital or remain in the RACF if they become acutely ill. Additional
wishes can be recorded over time. When adequate time has been taken to discuss relevant issues
related to advance care plans, the aged care team is better able to respond to questions as they
arise and as circumstances change. This may involve arranging for a legal representative to visit the
resident, ensuring appropriate privacy and providing assistance when needed.
4.3.1 Legal requirements
If the resident has lost their cognitive abilities, their appointed representative should be asked to
make such basic decisions at the time of, or soon after, admission.
In some jurisdictions, the appointment of an ‘enduring health advocate’ has been given legal
recognition by special legislation. This legislation allows a person to appoint someone to make
decisions about medical treatment on their behalf if they become incapable of making such
decisions for themselves. Such an appointment is made under an ‘enduring power of attorney
(medical treatment)’, sometimes referred to colloquially as a ‘living will’. Some forms of
artificial nutrition are regarded as medical treatment rather than palliative care (see Gardner; re
BWV [2003] VSC 173 [29 May 2003]). Therefore, a simple enduring power of attorney that
covers financial and lifestyle decisions, but not medical treatment, might not be sufficient to
ensure that a resident’s preferences regarding artificial nutrition can be acted upon.
A person who is required to make a decision on behalf of another person under an enduring
power of attorney (medical treatment) must take into account:
• what would be in that person’s best interests; and
• how that person would have acted if they were not incapacitated.
If a resident has already lost the capacity to make reasonable judgements, it is not possible for
them to appoint someone to make decisions for them under an enduring power of attorney
(medical treatment). If a decision needs to be made about continuing or ceasing artificial
nutrition for a resident in this situation, it might be necessary for a guardian to be appointed to
make the decision.
4.3.2 Documenting the plan
The best way to document advance care plans is in the resident’s case notes, or to note
recommendations for revisions to such plans when the resident’s circumstances change, as
directed by legislation in the particular State or Territory. Additionally, the following triggers
may help determine the need to reassess a resident’s advance care plan:
58 Guidelines for a Palliative Approach in Residential Aged Care