Advanced Care Planning

GPs develop ongoing and trusting relationships with their patients and are well-positioned to initiative and promote advance care planning (ACP). 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. Having an ACP means other people will not have to make decisions on a person's behalf without any knowlegde 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.

• Incorporate advance care planning as part of routine care of patients/residents during an ordinary consultation or as part of health assessment.
• Assess capacity of patient/resident to appoint a representative and complete an advance care plan.
• Support discussion and documentation of advance care plan.
• Apply the patient's/resident's wishes to medical care.
• Review plan regularly or when health status changes significantly.

When any individual gives permission to share an advance care plan, it can be forwarded to: 

Grampians Health Ballarat- Advance Care Planning Co-Ordinator

Fax: 5320 6493

and attached to the patients medical record, please mark the document for Advance Care Plan for filling in Alerts.

The minimum requirements are the patient's full name, date of birth, address, Grampians Health Ballarat Ur no (if known) and a telephone contact number for the patient.

• Initiating the discussion is often the most difficult, but also the most important step.
• Where possible, and consistent with the patient's wishes, involve family and, in particular, any Substitute Decision Maker (SDM) in the discussion.
• The opportunity to make an ACP should be part of routine care for all patients in residential aged care facilities.
• To maintain relevance, review of ACPs should occur on a regular, scheduled basis and also with any change in health or residential status.
• Communication of any ACP to all relevant healthcare providers is essential to ensure that ongoing care is congruent with the patient's wishes.
• There are many resources available to assist General Practice with advance care planning.
  (Adapted from Australian Family Physician 44/4 2015 pg:189)