Table 3 Target behaviours

Prepare frail elders for ACP conversations

• They understand what ACP means

• They know what will be discussed

• They are given time to prepare

• They are given the opportunity to involve those important to them.

Use the right approach to ACP conversations

• H&SCPs treat ACP as a normal, everyday conversation

• H&SCPs use an honest and frank approach that moves at the individual’s pace

• H&SCPs use a light-hearted approach, gentle language, and humour, where appropriate.

Make ACP relevant for the older person

• They understand the relevance of ACP to their life. H&SCPs can assist this by:

 • using frail elder’s past healthcare experiences, or those of family/friends, vignettes, storytelling, or reminiscence

 • explaining frailty’s likely trajectory to frail elders and their families

 • explaining key triggers to instigate ACP for frail elders

Remember relationships in ACP

• They are given the opportunity to involve those important to them.

• H&SCPs develop rapport and trust.

Lead ACP conversations with living well now

• H&SCPs start conversations by establishing current goals/what matters now to the frail elder

• H&SCPs avoid linking ACP solely with planning for the future, dying and death.

Communicate and confirm understanding of ACP with frail elders

• H&SCPs use clear, concise language, explain what ACP is and why it may be relevant to the frail elder

• H&SCPs summarise conversations and options, and check understanding.