This paper outlines the development of an advance care planning service, in partnership with general practitioners, specialists and facility staff that supports Nursing Home (NH) residents with dementia and their families. The aim of the service is to put a process in place whereby treatment options for residents, who have lost decision-making ability, can be considered in advance of any further episodes of illness. A 10 step plan was developed to implement Advance Care Planning within high level residential aged care facilities. Issues that arose during the course of the project are also discussed. The legal context for substitute decision-making is explained. Issues such as when to have these conversations, how to approach families, are discussed
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