Advance Care Directive in Aged Care Victoria

Why Residential Care Changes Everything About Your ACD

An Advance Care Directive (ACD) created when you're living independently at home doesn't always translate well to the realities of residential aged care. The clinical scenarios are different, the decision-making dynamics shift, and the physical environment means your directive may be interpreted and applied by staff who have never met you outside the facility.

If you or a family member is entering a residential aged care facility (RACF) in Victoria, the ACD should be reviewed — and often rewritten — to address the specific situations that arise in that setting.

When an ACD Gets Activated

Your ACD comes into force when a treating medical practitioner determines that you lack decision-making capacity for the specific treatment decision at hand. Capacity is decision-specific and can fluctuate: you might have capacity to decide about a meal plan but lack capacity to consent to surgery.

In the aged care context, activation commonly occurs during:

• Acute illness or infection. A resident develops pneumonia or a urinary tract infection and is too confused or unwell to consent to treatment. The treating GP or after-hours doctor checks for an ACD before deciding whether to transfer to hospital or treat in place.
• Progressive cognitive decline. Dementia progresses to the point where the resident can no longer understand treatment options. The ACD guides ongoing care decisions from that point forward.
• A fall or acute injury. The resident fractures a hip and is unconscious or in too much pain to consent to surgery. The ACD's treatment preferences (and the MTDM, if the ACD doesn't cover the scenario) determine the next steps.
• End of life. The resident reaches a terminal phase. The ACD governs decisions about pain management, hydration, hospital transfer, and resuscitation.

What Your ACD Should Address for Aged Care

General directives about refusing "heroic measures" are too vague for the aged care setting. A directive written for this context should specifically address:

Hospital transfer. Do you want to be transferred to a hospital for acute illness, or would you prefer to be treated within the facility? This is the single most common decision point in aged care. A clear instructional directive on hospital transfer can prevent unwanted ambulance trips and emergency department admissions.

Antibiotic treatment. Respiratory and urinary infections are frequent in aged care. Do you consent to antibiotic treatment to manage infections, or do you prefer comfort care only if the infection is likely to be life-limiting?

Artificial nutrition and hydration. If you can no longer eat or drink safely, do you consent to nasogastric tube feeding, PEG feeding, or intravenous hydration? Or do you prefer assisted oral feeding with the understanding that aspiration is a risk?

CPR and resuscitation. A clear refusal of cardiopulmonary resuscitation, if that's your preference, should be documented in clinical language that aligns with the facility's resuscitation protocols.

Pain management. Express your preferences for pain relief, including whether you consent to opioid medication even if it may hasten death as a secondary effect (this is legal under the doctrine of double effect in Victoria).

Getting Your ACD Into the Facility's System

When a resident enters an RACF in Victoria, the facility should ask about advance care planning documents during the admission process. But "should ask" and "reliably captures and files" are different things. Don't rely on the admissions team to handle this — be proactive:

1. Provide a certified copy of the ACD and MTDM appointment to the facility's care coordinator during admission. Ask them to confirm it's been scanned into the resident's electronic care plan.
2. Ask which GP services the facility. Residential aged care facilities often use visiting GPs rather than the resident's previous GP. The new GP needs a copy of the ACD.
3. Confirm the facility's resuscitation policy. Some facilities have their own policies about resuscitation — understand how your ACD interacts with these.
4. Flag the ACD at the nursing station. Some facilities use coloured stickers, alert flags, or specific file tabs to mark residents with active ACDs. Ask how the facility ensures nursing staff can identify residents with directives during a shift change.

Palliative Care and Terminal Illness

If you or a family member has a terminal diagnosis — cancer, motor neurone disease, end-stage heart failure, end-stage renal disease — the ACD takes on a different emphasis. The question shifts from "what treatments do I want if something unexpected happens" to "how do I want the final phase of my life managed."

Palliative care in Victoria is a right, not a privilege. Every Victorian has access to palliative care services regardless of whether they refuse curative treatment. Your ACD can include specific instructions about:

• Preference for palliative care over curative treatment once the condition becomes terminal
• Location of end of life care (home, hospice, hospital, aged care facility)
• Involvement of specific palliative care services or teams
• Spiritual or cultural requirements for end of life care
• Whether you consent to voluntary assisted dying (separate legal process under the Voluntary Assisted Dying Act 2017, but your ACD can express your awareness and preferences)

The Conversation That Matters Most

Entering aged care is one of the clearest trigger points for having the advance care planning conversation. If a parent is moving into residential care and doesn't yet have an ACD, this is the moment. Capacity can decline unpredictably once a person is in a facility, and completing the directive before admission is far simpler than trying to organise a GP witnessing appointment from within the facility.

The Victoria Advance Directive & Living Will Kit includes aged-care-specific treatment scenarios in the Treatment Decision Worksheet and a facility admission checklist that ensures your directive is properly embedded in the care system from day one.

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