An Advance Care Plan (or Advance Care Directive) is only as useful as its clarity, completeness, and accessibility. Building a robust plan means going beyond checkboxes to include context, values, treatments, decision-makers, and storage. In Australia, health services expect comprehensive documentation that helps clinicians align care with your wishes when you can’t speak. Below, we break down what to include in your plan, why it matters, and how to make it useable in real-world settings.
What is an Advance Care Plan (vs a Directive)?
An Advance Care Plan refers to the broader process: reflecting on your values, discussing with loved ones, and documenting preferences. A Directive (often a statutory or legally recognised document) typically formalises part of that plan—recording your treatment wishes and appointing a substitute decision-maker. In practice, your plan includes both narrative (“why it matters to me”) and formal instruction for clinicians. Resources from Advance Care Planning Australia help people integrate values and directives. (advancecareplanning.org.au)
Because state and territory laws differ, your directive must follow the correct form and witnessing rules in your jurisdiction (for example, NSW Health guidance, Victoria Health directive framework, WA Health directive, etc.).
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.
Why detail matters—clinician usability & clarity
Clinicians rarely have time for nuance in emergencies. What they need is:
- Clear instructions they can interpret
- Decision-maker name and contact
- Contingencies for situations you didn’t foresee
- Context to guide interpretation (your values, priorities, trade-offs)
The Australian Commission on Safety and Quality in Health Care includes advance care planning as a pillar of person-centred care, with emphasis on clarity and accessibility.
By including both narrative and instruction, your plan avoids ambiguity and helps health professionals act confidently.
Core components to include
Here’s a comprehensive checklist of what your Advance Care Plan should cover.
1. Introduction / Preface: “Why this matters to me”
Begin your plan with a short statement of why you’re planning—what matters to you, your values, your fears, and your vision of a “good life.” This narrative helps everyone interpret your choices with empathy. Biography or storytelling can add humanity—remember, it’s your voice that adds context beyond medical checkboxes.
2. Key values and guiding principles
List your core values that influence your care choices, such as:
- Maintaining independence
- Avoiding extended hospitalisation
- Having dignity and comfort
- Staying close to family and environment
- Spiritual or cultural priorities
These values are the lens through which decision-makers and clinicians interpret your directives.
3. Health states and trade-offs you’d prefer to avoid
You can describe scenarios you consider unacceptable—e.g.:
- Being permanently unconscious
- Relying completely on machines
- Chronic, unrelieved pain
- Losing ability to interact meaningfully
By naming these, you give decision-makers and clinicians guardrails. But avoid overly rigid “never ever” statements—while you may refuse treatment in such states, leave space for nuance where you might accept limited interventions.
4. Treatment preferences and refusals
This is where your plan gets operational. Options to include:
- Consent to interventions (e.g., antibiotics, dialysis, ventilation)
- Refusal of specific treatments (e.g., CPR, ICU, feeding tubes)
- Preferences in ambiguous states (e.g., “If there’s >50% chance of recovery to meaningful quality of life”)
- Priorities (e.g., comfort over maximum life extension)
Keep wording clinically interpretable (“no mechanical ventilation beyond 7 days,” or “if I can’t breathe independently long-term, comfort care only”). State/territory guidance and clinician input are useful here.
5. Appointment of a substitute decision-maker(s)
Your plan should clearly name the person(s) who can act for you. Include:
- Full name(s), contact information
- Alternate or backup name(s)
- Any boundaries or conditions (e.g., consult family, avoid aggressive interventions)
Be sure to use the proper legal mechanism in your jurisdiction to appoint them (for instance, Enduring Guardian in NSW, medical treatment decision-maker in Victoria, Advance Health Directive in WA, etc.). Check state/territory forms via Advance Care Planning Australia.
6. Communication preferences and involvement of family / others
You might include:
- Which family or friends should be informed or consulted
- Preferences around disclosure and privacy
- How and when you wish to be updated if incapacitated
These details help avoid conflict and surprise, especially when families disagree.
7. Preferred place of care and transitions
Where would you prefer to receive care? Options might include:
- At home (with support)
- In hospital
- In hospice or palliative care facility
- In aged care
You can also include preferences around transitions (e.g., transfer to hospital only if symptoms can’t be managed at home).
8. Symptom control, comfort, and palliative approaches
You may prioritise comfort even if that shortens life. Your plan can:
- Express your pain or symptom relief goals
- Indicate whether you would accept sedating medications
- Specify tolerance for side effects
- Clarify whether hospice or palliative care should kick in early
Many state health departments and Palliative Care Australia resources encourage people to prioritise symptom relief early, rather than delaying until crisis.
9. Spiritual, cultural, relational, or identity matters
In multi-cultural Australia, your cultural, spiritual, and relational integrity matters. You can include:
- Spiritual practices or rituals (e.g., last prayers, religious readings)
- Cultural needs (e.g., Country, kinship, clan obligations)
- How you wish your identity or relationships to be preserved or honoured
Including these signals to your healthcare team that your preferences aren’t purely medical—they’re part of your identity.
10. Practical, logistical, and legacy instructions
Your plan is more useful when you also provide operational direction:
- Insurance, legal contacts, assets, finances
- Location of important documents (will, powers of attorney, policies)
- House, pet, funeral, or digital legacy details
- Key passwords or contacts
A legacy platform like Evaheld can house all this in a protected vault, tied to your directive so that decision-makers have context when it matters.
11. Revisions and version control
Explicitly state:
- That this document replaces prior versions
- The date signed / witnessed
- A schedule for review (e.g., yearly, after serious events)
- Where updated versions are stored
Clarity on versions ensures that the most recent statement is followed.
12. Witnessing and legal compliance
Include:
- Signature lines for you and witnesses
- Witness names, signatures, and dates
- Declaration (if required) about your capacity
- Jurisdictional compliance clauses
If witnessing rules aren’t satisfied, your directive may be invalid—always follow local guidelines.
Putting it all together: Sample structure
Here’s a sample skeleton:
- Preface and purpose
- Values, beliefs, and guiding principles
- Unacceptable health states / trade-offs
- Treatment preferences and refusals
- Appointment of substitute decision-maker(s)
- How family / others should be consulted
- Preferred place(s) of care
- Comfort, palliative, symptom management
- Spiritual, cultural, identity instructions
- Practical and legacy instructions
- Revision/version control
- Signatures, witnessing, and validity clause
Each section may not apply in full—adapt to your life, beliefs, and state/territory rules.
Tips for better clarity and usability
- Use plain language, avoiding medical jargon where possible (or include clarifications).
- Use conditional statements carefully (“if X then Y”) to avoid ambiguity.
- Avoid blanket phrases like “everything possible”—those leave clinicians guessing.
- Keep context and narrative early so decision makers can interpret ambiguous cases.
- Review with a health professional to ensure language is clinically consistent.
- Provide a short summary version (e.g., 1-page “key points”) so in emergencies, staff see the essentials first.
Storage, sharing, and accessibility (so inclusion is real, not just theoretical)
Your plan—even a perfect one—is useless if it can’t be found. Ensure accessibility by:
- Giving copies to your substitute decision-maker, family, clinicians
- Requesting your GP or hospital clinic store the finalized plan in your medical chart
- Uploading it to My Health Record’s advance care planning section (via Digital Health Agency) so hospitals and GPs can see it in emergencies
- Storing the definitive version in a protected, accessible digital platform like Evaheld
- Informing relevant parties how to access the plan—especially where in the system it’s stored
Redundancy helps—if one route fails (document gets lost, records don’t sync), others may succeed.
Review, update, repeat
Your life changes; so should your plan. Include a clear statement that:
- You intend to review annually or after significant health/life events
- Updates must be signed, witnessed, redistributed, and uploaded
- The latest version is the legally operative one
Healthcare systems operate on the assumption that the newest valid document is followed—so consistency matters.
Common pitfalls to avoid in inclusion
- Vague statements (“I want dignity, no matter what”) without operational instructions
- Excluding decision-maker name or contact
- No contingency plans
- Improper witnessing
- Not uploading or sharing widely
- Leaving out spiritual, cultural, or relational context
- Forgetting to manage version control
A well-rounded plan anticipates real-world complexities—not just ideal scenarios.
Why completeness matters for you, your family & clinicians
- Your autonomy is honoured
- Families don’t guess or argue
- Clinicians can act confidently
- Surprises are minimised
- Decisions align with your life’s story, not fear or default
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!
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
- Launch Your Vault – Start free in minutes through the simple free Evaheld Legacy Vault..
- Invite & Open Rooms – Add loved ones and set up dedicated spaces to trade content requests.
- 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!
Share this post