How to Create an Advance Care Plan Step-by-Step

An Advance Care Plan (sometimes formalised into an Advance Care Directive) is one of the most meaningful preparations you can make for your future health care. It ensures your values, preferences, and voice help guide treatment decisions when you might not be able to speak for yourself.

Below is a practical, step-by-step guide (15 steps) to help you build, document, and share your plan in Australia — so your loved ones and health professionals can honour your wishes.

Why follow a step-by-step process?

Jumping straight to legal forms without reflection or conversations often leads to vague or contradictory statements. A structured process ensures your plan:

• Reflects your values, not guesswork
  
• Is understood by your substitute decision-maker
  
• Is clinically clear and useable
  
• Is stored, shared, and updated when necessary
  

The Australian Department of Health endorses this approach: start with reflection, then talk, document, and make it accessible. (Health and Ageing Department) And the Advance Care Planning Getting Started Guide lays out these same phases in its recommended sequencing. (Advance Care Planning Australia)

Get the free Legacy Letter Kit, or start for free in the Evaheld Legacy Vault—create and share your legacy letter for free in minutes.

Step 1: Prepare your mindset — “Be open, be ready, be heard”

Before doing anything, accept that this is a sensitive, ongoing process. The Getting Started Guide frames three attitudes: be open (reflect on values), be ready (talk), and be heard (document and share). (Advance Care Planning Australia) Approach the process as a gift you give yourself and your loved ones, not a burden.

Step 2: Educate yourself on your rights and local laws

Every Australian state and territory has its own rules, terminology, witnessing requirements, and forms. Use Advance Care Planning Australia to find your jurisdiction’s specific directives or guidelines. (Advance Care Planning Australia) Also, refer to the Australian Digital Health Agency for how to upload documents into My Health Record so they’re discoverable in emergencies. (Australian Digital Health Agency)

Understanding the legal context ensures your document is valid and helpful.

Step 3: Reflect deeply — values, fears, trade-offs

Begin by answering internal questions such as:

• What gives your life meaning (relationships, independence, dignity, spiritual connection)?
  
• What health states would you find unacceptable (loss of communication, complete dependence, constant pain)?
  
• What trade-offs would you accept (longer life vs comfort, aggressive treatments vs palliative care)?
  

The Getting Started Guide offers a structured reflection worksheet for this. (Advance Care Planning Australia)

Reflection ensures your later instructions aren’t just mechanical—they have emotional resonance and clarity.

Step 4: Choose who to involve in the process

Thinking and writing your preferences doesn’t have to be private. Key participants can include:

• A substitute decision-maker (or sometimes more than one)
  
• Close family or friends
  
• Your GP, specialist, or nurse
  
• Spiritual or cultural advisors
  
• Social workers or palliative care staff
  

QUT’s “How to do Advance Care Planning” guide emphasises that ACP is a team effort involving you, decision-maker(s), family, carers, and clinicians. (QUT)

Step 5: Start conversation(s)

Talking is essential. Use open, non-judgmental prompts like:

• “If I were seriously ill and couldn’t speak, what would I want you to know about me?”
  
• “What matters most to me is…”
  
• “What kind of care would I find unacceptable?”
  
• “Would I prefer comfort-focused care over aggressive interventions?”
  

Advance Care Planning Australia’s page ‘Talk about your choices’ helps with conversation starters and tips. (Advance Care Planning Australia)

You don’t have to cover everything at once—spread the dialogue across sessions.

Step 6: Identify and appoint your substitute decision-maker(s)

A plan without naming someone to act is weaker. Your substitute decision-maker:

• Should know your values well
  
• Must be willing to carry forward your preferences, even amid family disagreement
  
• Often is formally appointed depending on your state or territory
  

Your directive will typically include this appointment. But before you write, choose wisely and discuss the role with them.

Step 7: Draft your Advance Care Plan / Advance Care Directive

Now convert your reflections and conversations into a written document. What to include:

• Values and goals: what matters most to you
  
• Treatment preferences or refusals: what treatments you would or would not accept in certain situations
  
• Preferred place of care: home, hospital, hospice, aged care
  
• Cultural, spiritual, or relational preferences
  
• Appointment of substitute decision-maker(s) with name(s) and contact
  
• Any conditions or caveats
  

The Department of Health describes how an Advance Care Directive formalises your plan by gathering these elements into one document. (Health and Ageing Department)

Your directive form must follow the legal format and witnessing rules for your jurisdiction.

Step 8: Get professional review

Before finalising, let your GP, a trusted doctor, or specialist review your draft. They can:

• Clarify medical language
  
• Point out ambiguous or clinically impractical points
  
• Ensure your instructions are valid under your jurisdiction’s legislation
  

This step strengthens the usability of your plan in clinical settings.

Step 9: Formalise your directive with signatures and witnessing

This critical step ensures legal validity:

• Sign and date your document
  
• Witness according to your state or territory guidelines (often requires independent witnesses, capacity checks, etc.)
  
• Some jurisdictions require additional formal steps (registration, submission, etc.)
  

In NSW, for example, you can complete a written Advance Care Directive and upload it to My Health Record so it’s accessible. (NSW Health)

Be sure to follow your local rules exactly—incorrect witnessing can invalidate the directive.

Step 10: Store, share, and upload your plan

A plan is only useful if people and clinicians find it. Use a multi-layer distribution:

• Give copies to your substitute decision-maker, family, carers, and your GP
  
• Ask your hospital, aged care provider, or medical specialist to store a copy in your file
  
• Upload your plan to My Health Record via MyGov so it’s available in emergencies. The Digital Health Agency provides clear instructions on that. (Australian Digital Health Agency)
  
• Use a secure digital vault like Evaheld to store the authoritative version, background notes, and messages to family/caregivers
  

This layering ensures that the most up-to-date version is accessible when needed.

Step 11: Inform and orient your substitute decision-maker

Provide them with:

• A copy of the directive
  
• Your reflection notes or conversation summaries
  
• Guidance on how to advocate for you
  
• Access to your digital vault or where the document is stored
  

This reduces confusion later and helps them act confidently.

Step 12: Regularly review and update your plan

Your health, viewpoint, or family circumstances can change. Review:

• Annually
  
• After major life events (diagnosis, hospitalization, bereavement)
  
• If your substitute decision-maker changes
  

If you make changes, repeat the signing/witnessing step and redistribute the new version. The Department of Health emphasises that the most recent directive is the one followed. (Health and Ageing Department)

Step 13: Handle conflicts or ambiguities

Even with planning, ambiguity or disagreement can arise. In those cases:

• Your documented values and instructions provide guidance
  
• Your decision-maker should act in line with your wishes
  
• In unclear cases, health professionals may consult ethics committees
  
• Use clarity in your writing (avoid vague phrases like “do everything possible”)
  

A good directive reduces conflict, but cannot eliminate all ambiguity—so clarity up front helps greatly.

Step 14: Train close people on accessing it

Make sure your decision-maker, close family, and even secondary contacts know how to locate the document:

• Where the hard copy is stored
  
• In which folder or label in My Health Record
  
• How to access your Evaheld vault (if applicable)
  
• That the most recent version is what matters
  

Redundancy matters—if one route fails, others can succeed.

Step 15: Promote awareness and normalise planning

You can use your story to encourage others to plan. Normalising advance care planning helps reduce stigma, delay, or discomfort in others. Many health services and aged care providers now use ACP as part of routine care (e.g. in Western Australia, ACP is integrated into standard practice). (WA Health)

Common pitfalls (and how to avoid them)

Example flow (in brief)

1. Reflect on values and fears
   
2. Talk with loved ones / clinicians
   
3. Choose decision-maker(s)
   
4. Draft preferences and instructions
   
5. Seek professional input
   
6. Finalise with signatures and witnessing
   
7. Store, upload, and distribute
   
8. Train relevant people
   
9. Review and revise periodically
   

Why taking these steps matters

• It respects your autonomy, even when you cannot communicate
  
• It reduces burden and conflict for family and carers
  
• It improves care alignment, preventing unwanted treatments
  
• It increases the likelihood your wishes are honoured in emergencies
  

National and state policies affirm that advance care planning should begin when you’re well and be integrated into regular health care. (Health and Ageing Department)

Future-Proof Your Family’s Story: Why an Evaheld Legacy Vault Is the One Account You’ll Never Regret Opening

Imagine your great-grandchildren hearing your laugh, reading your life advice and seeing your Advance Care Directive in the same secure space—long after today’s social apps have vanished. That’s exactly what the Evaheld Legacy Vault delivers: a single, lifetime-guaranteed home for everything that matters, from milestone videos to legally valid health wishes. Below you’ll discover what the Vault does, why it’s different and how you can lock in a free account in minutes.

1. One Vault, Every Memory

Create rich, first-person history with in-browser video, audio, photos, written reflections, legacy letters and even ethical wills. Your stories live alongside recipes, playlists and private notes—ready to inspire loved ones for generations.

2. Dedicated “Rooms” for the People Who Matter

Open individual or shared rooms so each grandchild, sibling or friend has their own space to swap memories and request new ones. Two-way messaging keeps conversations vivid and private. Or invite entire families to a “Family Room” to ensure that your family’s history and legacy is all in one place - secure forever for future generations!

Add Unlimited Recipients, Start Unlimited Room, and Start Receiving and Sending Content Requests Now - It’s Free!

3. Advance Care Planning That Actually Gets Finished

The Vault walks you through Australia’s most intuitive Digital Advance Care Directive. Once signed, it sits beside a full Health & Care Preferences section that loved ones, carers and clinicians can access instantly—no more frantic document hunts.

4. Emergency Access That Saves Time and Protects Your Wishes

Print your QR Emergency Card; first responders scan it and see the latest directives in six seconds. Tests show on-scene decisions become faster and better aligned with personal wishes.

Watch why our work is so important to us.

5. Secure Home for Every Important File

Create and upload wills, powers of attorney, insurance details, super and bank info with bank-grade encryption. Granular permissions mean only the right people ever see the right files.

6. Key Contacts Always Up to Date

Keep one live list of attorneys, guardians, executors and advisors. Change a phone number once and it syncs everywhere—so your family never scrambles for contacts in a crisis.

How It Works

1. Launch Your Vault – Start free in minutes through the simple free Evaheld Legacy Vault..
   
2. Invite & Open Rooms – Add loved ones and set up dedicated spaces to trade content requests.
   
3. Create, Share & Relax – Let the built-in AI assistant tag, file and schedule everything while you go live life.

Why Thousands Are Preserving Their Legacy With Evaheld

• A Priceless Heirloom – Your Vault becomes a digital time capsule future generations will treasure.
  
• Ongoing Connection – Schedule birthday videos, graduation letters and milestone messages years ahead.
  
• Cross-Generational Peace of Mind – Families see care wishes and personal stories, reducing conflict and anxiety.
  
• Always Free for Early Users – Launch now and secure lifetime storage at zero cost on our freemium plan.
  

Dive Deeper Into Legacy & Care Planning

• Watch our Founder's Story to learn why we’re so passionate about Legacy Preservation and Advance Care Planning
  
• Follow our step-by-step guide to crafting a powerful legacy statement.
• Sign Up and Download a free Evaheld Legacy Letter Kit!
  
• Discover easy techniques for turning life lessons into messages.
  
• Get tips from our “How to Preserve Your Story” tutorial.
  
• See who we help in Evaheld Community.
  
• Sign up for free and discover the Evaheld Legacy Vault: What’s Inside a Vault.
  
• Hear real users explain why they signed up: Legacy That Loves Back.
  
• Read the full list of Vault benefits.
  

Extra Guidance

For guidance tailored to your needs, explore trusted dementia help sites, resources on family legacy preservation, online wills and estate planning platforms, and dedicated advance care directive resources. You’ll also find expert guidance and secure Evaheld Legacy Vault services, along with valuable information for nurses supporting end-of-life planning and values-based advance care planning. Evaheld is here to ensure your future planning is secure, meaningful, and deeply personal — with family legacy preservation resources designed to support your advance care planning, and those closest to you: families, carers, and communities.

Ready to Future-Proof Your Voice?

Opening an Evaheld Legacy Vault costs nothing, secures everything and takes less time than brewing a coffee. Your family’s story deserves a permanent, private home—claim it today and start creating memories that will matter forever.

Start your Evaheld Legacy Vault for FREE and secure your story and family legacy!

Evaheld’s “Connection is all we have” Hardship Policy

At Evaheld we believe that everyone’s story and legacy is worth sharing, so if you or someone you know needs some hardship assistance, please reach out and let us know, and someone from our team will ensure that money will not prevent anyone from securing their story, connections and legacy for loved ones and future generations. Because at Evaheld we believe that “Connection is all we have,” and that every single story and legacy is worth preserving!