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Objective: To assess the prevalence of advance care directives in the residential aged care facilities within the catchment for a single ED and to assess the systems in place for development of those advance care directives with focus on documentation and communication. Methods: A de-identified, paper-based, mail-out survey of all 30 residential aged care facilities potentially referring to the Wollongong Hospital ED. Results: A total of 24 of 30 surveys were returned. Thirteen facilities reported at least some proportion of their residents having documented advance care directives. The median prevalence of advance care directives was 5% of residents (interquartile range 0–10%). Discussions with residents over advance care directives were reported in 9 of 24 survey returns. Not all facilities that reported documenting advance care directives had processes for regular review or 24 h access to the documentation for carers. Ten of the survey returns reported general practitioner involvement in advance care directive development. Conclusion: The facilities surveyed reported that advance care directives are the exception rather than the rule. Where they were developed some facilities did not ensure regular review, dissemination of the information nor consistent involvement of the GP. This demonstrates low utilization and poor application, which has implications for care appropriate to patients' wishes and for resource use within the ED. [ABSTRACT FROM AUTHOR]