Advance Care Planning for Aged Care in NSW

The moment a parent receives an Aged Care Assessment Team (ACAT) referral or a diagnosis of early cognitive decline, the window for documenting their healthcare preferences begins closing. Once they've moved into a residential aged care facility and their cognition deteriorates further, executing legally valid planning documents becomes far more difficult — and potentially impossible.

In New South Wales, advance care planning for aged care involves three separate instruments that work together: a common-law Advance Care Directive for treatment preferences, a statutory Enduring Guardian appointment for healthcare and lifestyle proxy decisions, and a financial Enduring Power of Attorney. Missing any one of these creates gaps that aged care facilities, banks, and hospitals will not bridge for you.

Why Aged Care Admission Triggers Urgent Planning

The transition to residential aged care typically marks a shift in who controls daily medical decisions. While your parent is living at home and competent, they make their own choices about treatment, medication, and hospital admissions. Inside a facility, decisions happen faster and involve more people — nursing staff, visiting GPs, geriatricians, and sometimes hospital emergency departments.

Without an Advance Care Directive and Enduring Guardian already in place, the facility's clinical staff must identify a "Person Responsible" under the statutory hierarchy in the Guardianship Act 1987 every time a treatment decision arises. The hierarchy runs through guardian, spouse or de facto partner, unpaid carer, then close relative or friend. When there are multiple adult children who disagree about Mum's care — one wants aggressive treatment, another wants comfort care — that hierarchy produces conflict, and conflict produces tribunal applications to NCAT.

An Advance Care Directive drafted before admission removes ambiguity. The nursing home's care team can refer directly to the resident's documented preferences for CPR, hospitalisation, antibiotic treatment for infections, and artificial nutrition. A named Enduring Guardian can authorise or refuse treatment without waiting for family consensus.

What to Document Before Admission

Aged care planning should address the clinical scenarios most likely to arise in a facility setting:

Acute deterioration — whether to call an ambulance and transfer to hospital, or manage the event in the facility with comfort measures. Many residents are transferred to emergency departments by default because no documented preference exists.

Infection management — whether to treat recurrent infections (pneumonia, urinary tract infections) with antibiotics or transition to palliative comfort care. For residents with advanced dementia, repeated courses of antibiotics can prolong suffering without improving quality of life.

Artificial nutrition and hydration — whether to insert a nasogastric or PEG feeding tube if the resident loses the ability to swallow. This is one of the most common triggers for family conflict in aged care settings.

CPR and resuscitation — whether to attempt cardiopulmonary resuscitation. For frail elderly residents, the realistic survival rate after in-facility CPR is low, and the risk of rib fractures, brain damage from oxygen deprivation, and prolonged ICU admission is high.

Hospitalisation threshold — at what point the resident should be kept in the facility for palliative care rather than transferred to a hospital emergency department.

The Enduring Guardian's Role in Aged Care

Your Enduring Guardian makes decisions that go beyond just medical treatment. In the aged care context, their authority can extend to:

• Consenting to changes in the level of care (moving from low care to high care within a facility, or between facilities)
• Deciding on accommodation if the current facility can no longer meet the resident's needs
• Authorising personal services — physiotherapy, allied health visits, pastoral care
• Refusing medical treatment that conflicts with the resident's documented wishes

When drafting the Enduring Guardian appointment, use Clause 5 of the statutory form to include specific directions relevant to aged care. For example: "My guardian must not consent to my transfer to a hospital emergency department for treatment of a non-life-threatening condition if I am receiving palliative care in my residential facility."

Getting the Timing Right

The legal requirement for all three documents is that the person making them has decision-making capacity at the time of signing. For someone entering aged care with early-stage dementia, this means acting promptly — early-stage cognitive decline does not automatically remove legal capacity, but the window narrows with each month.

If there is any doubt about capacity, arrange a formal capacity assessment with the person's GP or a geriatrician before executing the documents. A medical assessment confirming capacity at the time of signing creates a strong legal defence against any future challenge to the documents' validity.

The Enduring Guardian appointment must be witnessed by a prescribed witness — a solicitor, Local Court Registrar, or approved NSW Trustee & Guardian employee. The witness must certify that the person appeared to understand the document's effect and signed voluntarily. If the witness has concerns about capacity, they are legally required to refuse to sign the certificate — which is exactly why you want the medical assessment done first.

Integrating Documents with the Facility

Once the documents are executed, integration with the aged care facility is essential:

• Provide the admissions team with certified copies of the Advance Care Directive and Enduring Guardian appointment
• Ask the facility to scan both into the resident's care file and flag them in the clinical notes
• Confirm that the facility's GP has a copy and understands the resident's treatment preferences
• Upload a PDF of the Advance Care Directive to the resident's My Health Record
• Ensure the Enduring Guardian's contact details are listed as the primary decision-maker in the facility's records

The NSW Advance Directive & Living Will Kit includes aged-care-specific treatment clauses, a document storage checklist, and a clinical translation reference so your parent's wishes are recorded in language that nursing staff and visiting doctors can act on immediately.

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