Advance care planning: empowering older frail people to document their end of life wishes

Peter Gonski; Melissa Chan; Ken Hillman

doi:10.1071/AH25060

RESEARCH ARTICLE (Open Access)

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Advance care planning: empowering older frail people to document their end of life wishes

Peter Gonski

^A ^B ^* , Melissa Chan

^A and Ken Hillman

^B ^C

+ Author Affiliations

- Author Affiliations

^A Southcare, Sutherland Hospital, Caringbah, Sydney, NSW, Australia.

^B UNSW, Sydney, NSW, Australia.

^C Liverpool Hospital, Liverpool, Sydney, NSW, Australia.

^* Correspondence to: Peter.Gonski@health.nsw.gov.au

Australian Health Review 49, AH25060 https://doi.org/10.1071/AH25060

Submitted: 18 March 2025 Accepted: 22 March 2025 Published: 9 April 2025

© 2025 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Objective

To determine the features that are required to increase uptake of advance care directives (ACDs).

Methods

We conducted a study involving older patients attending aged care outpatient clinics and/or receiving outreach services between March 2021 and December 2022. Patients were assessed using tools related to frailty, end of life and empowerment. If the person agreed to complete an ACD, they were guided through it, and it was subsequently uploaded on the electronic medical record.

Results

Of 170 patients referred to complete an ACD, 47% completed it. These patients had lower Rockwood Clinical Frailty Scale and SPICT (Supportive and Palliative Care Indicators Tool) scores. The Frailty and SPICT tools were easier to use, the PAM (Patient Activation Measure) was difficult to use and assess. Patients did, however, show satisfaction in the process.

Conclusions

Patients completing an ACD tended to be a little less frail and less likely to die in the following 12 months. Increased uptake of ACD is more likely if the less frail are targeted, and assisted through the process by a health professional at a time and place that suits the person.

Keywords: advance care directive, aged, end of life, frailty, planning, SPICT.

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