4. Care planning

Establish the goals and needs of the person, their family and carers to ensure the person’s preferences and needs are reflected

Care planning establishes the care goals and needs of the person, their family and carers. Individuals should be involved as much as possible in their care planning, to ensure their preferences and needs are reflected. Recognising variation in community and cultural preferences and expectations of care will help to support a person-centred approach for all. Multicultural health and Aboriginal health professionals can provide cultural guidance and support and, where applicable, be part of the multidisciplinary team.


Processes are in place to ensure that following comprehensive assessment of people with life-limiting illnesses, the person, their family and carers are actively involved in discussions and decisions regarding immediate care needs and advance care planning.

Appropriate documentation must reflect these decisions.


Care planning is important to support meeting the goals and needs of the person with life-limiting illness, their family and carers.

Considerations and resources

Advance care plans must be readily available for current and future care providers, including during unplanned and out-of-hours care (including formal documents, such as advance care directives).

Advance care planning information and resources are available on the NSW Health website and tools such as the End of Life electronic medical record (eMR) solution can improve shared care planning across multiple settings.

Care plans need to be communicated with the person’s general practitioner and original referrer.

Processes must be in place to ensure periodic reassessment of patient and family/carer needs, as these needs may change over time. This includes the provision of relevant health literate information.


Shared decision making

Last Days of Life Toolkit: Asking questions can help: For friends or carers of people approaching the last days of life

Questions family members or carers may want to ask when their relative or friend’s condition deteriorates, or a decision is made to initiate a palliative approach to care.

Clinical Excellence Commission | Information | 2016

Last Days of Life Toolkit: Asking questions can help: For people when approaching the last days of life

Questions a patient may ask when they deteriorate, or a decision is made that there are no reversible causes of deterioration.

Clinical Excellence Commission | Information | 2016


Cloud-based document for people in their last year of life for sharing information.

Hunter New England Local Health District | Information | 2021

Palliative Care NSW

The peak body and leading voice in NSW promoting quality palliative care for all.

Palliative Care New South Wales | Information | 2021

Management planning

CareSearch: Planning Care

Evidence-based information to support best practice palliative care, for health professionals.

Australian Department of Health | Information | 2021

Talking about Palliative Care

Encourages people of all ages and health status to talk about death and dying.

Palliative Care Australia | Information | 2021

Dying Well: Improving palliative and end of life care for people with dementia

Discussion paper which examines the state of end of life and palliative care for people with dementia and their families.

Dementia Australia, Victoria | Information | 2019

End-of-life Essentials

Provides online learning opportunities and practice resources for doctors, nurses and allied health professionals to improve the quality and safety of end-of-life care in hospitals.

Flinders University | Educational | 2021

Last Days of Life Toolkit: Guidance for recognising dying; management planning and care after death - adult patients

Assists in the recognition of the dying patient and development of individualised management plans.

Clinical Excellence Commission | Information | 2017

NSW Paediatric Palliative Care Programme

Provides information for patients, families and health professionals who care for a child with a life-limiting illness.

Sydney Children's Hospital Network | Toolkit | 2021


The palliative care evidence and practice information resource for the Australian aged care sector.

Flinders University | Information | 2021

The AMBER Care Bundle

A systematic approach for the multidisciplinary team to follow when clinicians are uncertain whether a patient may recover.

Clinical Excellence Commission | Toolkit | 2020

Using Resuscitation Plans in End of Life Decisions

Standards and principles relating to appropriate use of resuscitation plans by NSW public health organisations for patients 29 days and older.

NSW Ministry of Health | Clinical tool | 2014

Advance care planning

Advance Care Planning

Resource for NSW patients, families, carers and health professionals to get information on advance care planning.

NSW Ministry of Health | Information | 2020

Advance Care Planning: Information for health professionals

Information for NSW health professionals on advance care planning.

NSW Ministry of Health | Educational | 2020

Advance Care Planning Australia

A national program which enables Australians to make the best choices for their future health and care.

Austin Health | Information | 2020

Advance Care Planning: Making your wishes known

Advance care planning information brochure available in multiple languages.

NSW Multicultural Health Communication Service | Information | 2017

Dignity, Respect and Choice: Advance Care Planning for End of Life for People with Mental Illness

Support people with mental illness with complex issues around advance care planning.

NSW Ministry of Health | Toolkit | 2015

Making an Advance Care Directive

Information to help people complete an advance care directive

NSW Ministry of Health | Information | 2019

My Health Record

A digital platform for storing personal health information, which can be accessed by patients and authorised health professionals.

Australian Digital Health Agency | Clinical tool | 2021

NSW Ambulance authorised plans

NSW Ambulance Authorised Care Plans

Enable paramedics to provide individualised care to patients who have a life limiting illness, in their home or in a residential aged care facility.

NSW Ambulance | Clinical tool | 2019

Previous Guideline index Next