Advance Care Planning Is Not a One-Time Task

Creating an advance care plan is one of the most empowering steps a person with dementia can take. It ensures that their medical wishes, personal values, and spiritual beliefs are respected when they can no longer speak for themselves. But the most effective plans aren’t static — they evolve over time.

Regularly reviewing and updating an advance care plan ensures it reflects current preferences, health changes, and family circumstances. It also strengthens communication between loved ones, carers, power of attorneys, and medical teams — reducing confusion and distress when decisions must be made quickly.

Using secure tools like Evaheld, families can store care plans, update preferences, and preserve personal reflections — keeping the person’s voice at the centre of their care journey.

Why Reviews Are Essential in Dementia Care

Dementia is a progressive condition. As it advances, the individual’s ability to communicate or understand complex decisions may decline. Regular reviews allow families to adjust the care plan as new challenges or questions arise.

According to Dementia Australia, failing to review advance care directives can lead to outdated instructions that no longer reflect the person’s best interests — especially if their health status or environment has changed.

Reviewing the plan also gives families the chance to revisit sensitive topics with compassion, update key documents, and reaffirm the individual’s values and legacy goals.

When Should Advance Care Plans Be Reviewed?

While there’s no one-size-fits-all schedule, certain events should always prompt a review:

• Change in health status (e.g., new diagnosis, hospitalisation, decline in function)
• Change in care setting (e.g., moving to residential care or home support)
• Loss or change of decision-maker (e.g., change in power of attorney)
• Significant family changes (e.g., death, estrangement, reunion)
• Annually — even without changes, a yearly review ensures peace of mind

The Evaheld Legacy Vault allows families to store these documents securely and update them in real time, with notifications to keep everyone aligned.

What to Review in an Advance Care Plan

Here’s what families and carers should look at during each review:

1. Medical Preferences

Are the individual’s treatment goals still the same? Would they accept life-prolonging treatments, or prefer comfort care? Preferences around CPR, feeding tubes, hospital transfers, and medication should be revisited with medical teams.

2. Spiritual and Emotional Wishes

Are there new preferences around music, rituals, or who they want nearby during critical moments? These are just as important as clinical directives and can be recorded using Evaheld.

3. Decision-Makers

Is the nominated power of attorney still able and willing to serve? Are they informed about current preferences? Do they need a refresher or support?

4. Location of Care

Does the person still wish to remain at home if possible? Has their condition made residential care a better option? Review any transitions and update accordingly.

5. Legacy and Life Reflections

Has the individual added new reflections or legacy content they want preserved or shared? This may include letters, photos, videos, or recorded wishes for future generations.

Involving the Person Living with Dementia

If the person is still able to participate, their voice must be prioritised. Involve them in discussions using clear, simple language. Ask:

• “Are you still comfortable with the care we’ve planned?”
• “Is there anything you’d like done differently now?”
• “Would you like to add or change anything for the future?”

For those in later stages of dementia, legacy platforms like Evaheld allow family members to reflect and add updates on their behalf — based on previous conversations and shared values.

Supporting Carers and the Sandwich Generation

Carers — particularly those in the sandwich generation — face enormous pressure balancing family, work, and dementia support. Having a clear, current plan reduces mental load, helps with decision-making, and supports emotional wellbeing.

Using tools like Evaheld to coordinate reviews, send reminders, and centralise updates makes it easier to maintain consistency and avoid miscommunication between multiple carers or facilities.

The Evaheld Blog also provides step-by-step guides to support carers through planning, updates, and family discussions.

Integrating Reviews Into Everyday Life

Here are five simple ways to make advance care plan reviews part of your regular routine:

1. Set an Annual Review Date

Mark it in your calendar, perhaps around the person’s birthday, or the anniversary of diagnosis.

2. Link to Medical Check-Ups

Include a care plan review during annual GP visits or when updating medication or diagnoses.

3. Schedule a Family Meeting

Gather those involved in care to review updates together, clarify responsibilities, and resolve concerns.

4. Document the Review

Use Evaheld to note who was involved, what was changed, and the reason for the update.

5. Share the Updated Plan

Ensure healthcare providers, carers, and attorneys have the most recent version — with digital access if possible.

Benefits of Regular Advance Care Plan Reviews

• Honours changing wishes
• Improves care consistency
• Reduces family conflict
• Prepares for emergencies
• Supports carers emotionally and practically
• Protects the dignity and autonomy of the person with dementia

As dementia progresses, having a clear, up-to-date plan is one of the most important ways to advocate for the person’s comfort and legacy.

According to Advance Care Planning Australia, reviewed plans are far more likely to be followed accurately — especially when they reflect the individual’s evolving needs.