Synopsis
Use voluntary, person-led advance care planning to translate an older adult's values into clear, lawful and reviewable plans for future deterioration.
- Advance care planning is voluntary and may begin months or years before the last days of life.
- Start with what matters, feared outcomes, acceptable function and the person's preferred balance between longevity and treatment burden.
- Capacity is presumed and assessed for the specific decision at the time; frailty, dementia or age alone never proves incapacity.
- An advance statement guides future best-interests decisions but is not the same as a legally binding advance refusal.
- An advance decision to refuse treatment must be valid and applicable; additional formalities apply when life-sustaining treatment is refused.
- A health-and-welfare attorney only has the authority actually granted and normally acts only after the donor lacks relevant capacity.
- Record clinical recommendations separately from personal wishes, because neither a preference nor an emergency plan guarantees clinically inappropriate treatment.
- Review after meaningful change, share across settings with consent, and give the person an accessible copy.
Key red flags
A supposedly binding refusal is unavailable, internally inconsistent or does not clearly cover the proposed life-sustaining treatment.
The person is being pressured by relatives, carers or professionals to accept a plan that does not reflect their own priorities.
New delirium, pain, hypoxia, hearing loss or communication difficulty may be impairing a conversation that is being treated as settled.
A transition between home, ambulance, care home and hospital has occurred without an accessible copy or reliable electronic record.
Family conflict, safeguarding concern or disagreement about legal authority is delaying necessary comfort treatment or urgent clinical assessment.
Investigation priorities
Define prognosis, reversibility and treatment burden.
Management branches
Frailty or progressive disease makes future loss of capacity or sudden deterioration reasonably foreseeable.
- Ask permission, assess communication needs and establish what the person already understands about their health.
- Explore what matters, unacceptable outcomes, preferred involvement of others and the person's desired level of prognostic detail.
- Link realistic clinical options to likely function, comfort, place of care and burdens rather than presenting decontextualised procedures.
- Agree specific next actions, document uncertainty and give the person time to reflect or continue later.