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Advance care planning

Note: Australian states and territories have different jurisdictions governed by different legislation.  In Victoria, legislation covering specific parts of an advance care plan, or directive, includes the Medical Treatment Planning and Decision Act 2016 and Guardianship and Administration Orders: guardianship information is also at the Office of the Public Advocate.  Different legislation applies in the jurisdictions of other states and territories.

When you start advance care planning, to complete an advance care directive, make sure you follow the information for the state, or territory, in which you live.

Visit and browse the information, the intent of information on advance care planning is essentially the same, with different information appealing to different people.

Enduring Power of Attorney (EPA)
Enduring Power of Attorney (Medical Treatment)
Enduring Power of Guardianship
‘Take Control’
  • Office of the Public Advocate                                                             Back to Top
  • Take Control
    ‘Take Control’ has clear information about powers of attorney and guardianship, step by step instructions, including all the forms you may need.
Refusal of Medical Treatment
  • Office of the Public Advocate
  • Refusal of treatment certificate
    Medical treatment for a current medical condition can be refused by signing a Refusal of (medical) Treatment Certificate; this certificate cannot be used to refuse palliative care, i.e. reasonable pain relief and food and water while you are still able to eat and drink.  If you have appointed an attorney under an enduring power of attorney (medical treatment), they can refuse medical treatment on your behalf.
Advance Care Planning (Department of Health, Victoria)
  • Department of Health
    Includes video clips ‘Starting the conversation’, ‘Putting it in writing’, ‘Making it easier for everyone’ and ‘Closing thoughts’.
  • Advance care planning FAQs
    Frequently asked questions for Victoria.
A national framework for advance care directives
  • This publication (Sept 2011) points out different and common ground across the jurisdictions of Australia.  Page 8 has an excellent patient journey chart; the chart helps clarifies what could be happening when and what to do about advance care planning.
Advance care planning for Aboriginal and Torres Strait Island people

Carers and respite

Carer Support Programs
  • This audit document, (Aug 2012) by the Victorian Auditor-General’s Office (VAGO), examined whether the Department of Health and the Department of Human Services effectively recognise and support carers.
Guide for family and friends
Respite services for children with life threatening illness
Demographic Analysis of Care Needs and Service Provision


 A Guide for living well with Memory Loss and Dementia
Services for people with dementia and their carers                Back to Top
Dementia practice guidelines for HACC assessment services
  • Strengthening assessment and care planning Dementia practice guidelines for HACC assessment services (May 2012) Department of Health
    This guide aims to (i) develop consistency of practice by describing the policy, concepts and thinking behind Living at Home Assessments (ii) describe assessment and care planning skills and techniques which will assist assessors in moving to a person-centred, active service model (ASM) approach and (iii) provide information and resources to support HACC assessors in their day-to-day practice.
Planning dementia services
  • Dementia services pathways – an essential guide to effective service planning Department of Health and Ageing
    This guide aims to inform and assist jurisdictions with service planning, by developing service pathways.  The guide describes the services required to meet the needs of people living with dementia and their carers across the dementia continuum.  Service pathways are useful as a planning tool to encourage key service providers to participate in planning activity and to coordinate service responses.
Behaviour management                                                           
  • Behaviour management – a guide to good practice (May 2012) Dementia Collaborative Research Centres
    Evidence-based guidance for clinicians in their role of assisting residential aged care facility staff, community care staff and family members caring for persons living with dementia, who present with behavioural and psychological symptoms of dementia (BPSD).
Being with people with dementia


Aboriginal and Torres Strait Islander people                           Back to Top
Diverse communities                                                                Back to Top
  • An outline of different cultural beliefs at the time of death (Oct 2011) Loddon Mallee Palliative Care Consortium
    Brief resources to assist healthcare workers understand different cultural or religious approaches to death and dying.  The resources should not be seen as prescriptive or fully detailing all the intricacies of a given religion or culture, nor is intended to be a definitive statement indicating how individuals may wish to be treated during or after their death.
  • Multicultural Palliative Care Guidelines (2000) Palliative Care Australia
    The words ‘death’, ‘dying’ and ‘cancer’ are taboo for many cultures and create immediate difficulties in palliative care.  Each participant in a conversation also represents various factors to the other, in areas such as age, status, and gender and, at times disability.  Questions that we may regard as ‘standard’ may offend or embarrass others.
  • Palliative care for culturally and linguistically diverse communities (Aug 2009)
    This resource was developed to help palliative care providers care for people from CALD backgrounds and to build sensitivity to basic cultural differences; it considers social, emotional, physical and spiritual needs.  This resource helps develop strategies to provide culturally appropriate services specifically for Cambodian, Chinese, Indian, Iranian, Sri Lankan and Vietnamese communities.

  • Cultural responsiveness framework: guidelines for Victorian health services (2009) Department of Health
    This guide outlines the newly endorsed Cultural responsiveness framework for Victorian health services. The framework encompasses a strategic and whole of organisation approach and is designed to be aligned with health services’ strategic planning processes.  The framework is based on four key domains of quality and safety, organisational effectiveness, risk management, consumer participation and effective workforce.
  • Strengthening diversity planning and practice – Grampians Regional Diversity Plan 2012-15 (May 2012)
    This document provides pertinent demographic and health issues in the Grampians region for HACC diversity planning, e.g. in Grampians region, life expectancy is lower than the Victorian average and the burden of disease is higher.

Grampians region information

Grief and bereavement

Bereavement support standards                                              Back to Top
Complicated grief
  • A systematic review of the literature on complicated grief (Mar 2011) Department of Health and Ageing
    “Complicated Grief” in this review is grief involving the presentation of certain grief-related symptoms at a time beyond which is considered adaptive.  These symptoms include (i) separation distress, such as longing and searching for the deceased, loneliness, preoccupation with thoughts of the deceased and (ii) symptoms of traumatic distress, such as feelings of disbelief, mistrust, anger, shock, detachment from others, and experiencing somatic symptoms of the deceased.

Palliative care

Victorian state policy
  • Strengthening palliative care: Policy and Strategic directions 2011 – 2015 (2011) Department of Health
    This policy provides details about the priorities and actions for palliative care and should be read in conjunction with the priorities of the Victorian Health Priorities Framework 2012–2022: Metropolitan Health Plan.
  • Strengthening palliative care: Policy and strategic directions 2011- 2015 Implementation strategy (2012) Department of Health
    This strategy sets out the actions that will be taken towards achieving the policy’s vision, which is to ensure that Victorians with a life-threatening illness and their families and carers have access to a high-quality palliative care service system that fosters innovation, promotes evidence-based practice and provides coordinated care and support that is responsive to their needs.
  • Strengthening care for children with a life-threatening condition (2008) Department of Human Services
    This policy outlines the principles underpinning care for neonates, infants, children and adolescents with a life-threatening condition, and their families and the relationships that are critical to providing care in an appropriate and timely way.
  • After-hour palliative care framework (Feb 2012) Department of Health
    Access to after-hours support has been a requirement for all Victorian community palliative care services since 1997.  The Department of Health’s policy and funding guidelines define business hours as normally falling between 7 am and 4.30 pm Monday to Friday, not including public holidays.  All other times are ‘after-hours’.  The guidelines describe the minimum level of service for after-hours community palliative care including (i) telephone advice to carers and families about symptom management if required and (ii) a nursing visit if the service assesses that a visit is required and it is safe for staff to visit.
Additional palliative care resources                                        Back to Top
  • The IAHPC Manual of Palliative Care 3rd Edition (Sept 2013)
    The International Association For Hospice and Palliative Care (IAHPC) publishes this clinical manual for health care professionals in palliative care.
  • Palliative Care Services in Victoria (Feb 2012)
    Published by Palliative Care Victoria, this five page document provides a range of interesting snapshot of palliative care and palliative care in Victoria.
  • Palliative Care Australia Annual Review 2012
    Palliative Care Australia is the peak national organisation representing the interests of all those who share the ideal of quality care at the end of life; this document provides an excellent overview of current palliative care.
Disability residential services
End of life care
GP palliative care information
  • Doctor’s bag: palliative care information (2011) Ballarat and District Division of General Practice Inc.
    A doctor’s resource for symptom control for symptoms commonly experienced in palliative care; updates of new drug lists are available at the above link.
National information

Seniors, ageing and residential care

Victorian resources
National resources
  • Australian Government Directory of Services for Older People 2012–2013
    A guide to Australian Government programs and services of interest to older people including health, care needs, legal rights, and finance and employment choices.  Some services are especially relevant to certain sectors of the community; symbols have been used to help identify these groups.
  • Living longer, living better – Aged care reform package (Apr 2012)
    Department of Health and Ageing
    The Aged Care Reform package will modernise Australia’s aged care system.  It will deliver immediate benefits to older Australians and the broader community, while laying the foundations for longer term reform.  It will strike the right balance between essential and much-needed changes and ensure the pace of change does not compromise the capacity of the current system to continue to deliver care at a time of transition.
  • National ageing and aged care strategy for people from CALD backgrounds (2012) Department of Health and Ageing
    This strategy informs and assists the Department of Health and Ageing (DoHA) implement the Living Longer Living Better aged care reform package; it also helps aged care services support older people from CALD backgrounds, their families and carers to continue to contribute to and engage with their communities.
  • Evaluation of the consumer-directed care initiative – final report (Jan 2012) Department of Health and Ageing
    This document aims to provide community aged care consumers with greater control of their lives by allowing them to make informed choices about the type of care services they access and the delivery of the services, including who will deliver the services and when they are delivered.
  • Encouraging best practice in residential aged care program – final report (Nov 2011) Department of Health and Ageing
    The Encouraging Best Practice in Residential Aged Care (EBPRAC) program represents the most comprehensive, coordinated, approach to implementing evidence-based practice in residential aged care (low and high level care) undertaken in Australia.
  • Guidelines for a palliative approach in residential aged care (May 2006) Australian Department of Health and Ageing
    This document provides evidence-based guidelines for the implementation of the palliative approach by all those caring for people with a life-limiting illness or condition in residential aged care facilities.
  • Guidelines for a palliative approach in the community setting (Jun 2011) Australian Department of Health and Ageing
    This document was developed as a companion document to the Guidelines for a palliative approach in residential aged care.
  • Affirming life – what is a palliative approach? A guide for family and friends with loved ones in aged care
    This guide provides information for family and friends to help them understand the palliative approach provided in residential aged care and encourage a partnership between family/friends and residential aged care service providers; this guide is based on the above Guidelines for a palliative approach in residential aged care (May 2006).


  • Strengthening palliative care: Palliative care volunteer standards (2007) Department of Human Services
    Volunteers are an essential component of the palliative care in Victoria and provide a unique avenue for clients, carers and families to be supported by their local community; the standards provide program standards and volunteer service standards for the Victorian palliative care sector.                                       Back to Top