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Advance Care Planning

What is Advance Care Planning?

Advance Care Planning (ACP) involves a patient thinking about, and communicating to others how they would like to be treated in the future if they have a condition where they can no longer speak for themselves or make adequately informed decisions concerning their future healthcare. This may happen for example as a result of stroke, progressive dementia, or becoming unconscious from some sort of accident or illness.

An Advance Care Directive (ACD) is a component of an Advance Care Plan and contains information relevant to specific areas of healthcare and the values and wishes of an individual which would be expected to impact on treatment options. Numerous directives have been developed by a variety of organisations to meet the needs of our diverse population. Any written and recorded statement of wishes is legally binding. Endorsement by a medical practitioner is recommended but not essential.

Why Advance Care Planning is important

Undertaking ACP means that future decisions about a person’s care are more likely to reflect their wishes. ACP identifies sensitive issues and clarifies the actions an individual would prefer in certain medical situations should they occur in the future. For many reasons these topics of discussions between family, carers and GPs are often avoided.

Having an ACP means people will not have to make decisions on a person’s behalf without any knowledge of that person’s feelings or wishes. It also reduces the likelihood of confusion and conflict regarding decisions of care between all parties involved. With an ACP in place a person can feel comfortable and reassured that there will be a common and calm approach to their care toward end-of-life.

What does ACP involve for GPs?

The role of GPs in advance care planning may include:

  1. discussing the idea of advance care planning with patients/residents
  2. providing patients/residents with information regarding their current health status, prognosis and future treatment options
  3. witnessing or completing instructional directives where appropriate
  4. applying patients’/residents’ wishes to medical management
What are the steps involved?
  1. Incorporate advance care planning as part of routine care of patients/residents during an ordinary consultation or as part of health assessment
  2. Assess capacity of patient/resident to appoint a representative and complete an advance care plan
  3. Support discussion and documentation of advance care plan
  4. Apply the patient’s/resident’s wishes to medical care
  5. Review the plan regularly or when health status changes significantly
Advance Care Directive templates

Visit the SLHD website for templates in documenting an advance care plan.

Useful links that may assist decision making and planning

  • The Royal Australian College of General Practitioners has guidelines on Advance Care Planning.
  • Dementia Australia has developed the Start2Talk resources to assist with advance care planning.
  • In response to requests from lawyers and medical professionals, New South Wales Government – Attorney General’s Department has developed a guide to assessing capacity to make legal, medical, financial and personal decisions.
  • NSW Ministry of Health has developed a plan to encourage adoption of Advance Care Planning.

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