Project Officer: Vijay Ramanathan
Phone: 8752 4915

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What is Advance Care Planning?

Advance Care Planning 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 themself. This may happen, for example, because of a stroke, progressive dementia, or becoming unconscious from some form of accident or illness. For more information, please visit ACP Information Sheet for GPs

Advance Care Planning used to be called Advance Care Directives and many web sites still utilise this terminology. Another term is Respecting Patient Choices.

Why Advance Care Planning is important?

Undertaking ACP means that future decisions about a person’s care are more likely to reflect their wishes. It helps them raise sensitive issues about the future with those close to them that they might otherwise avoid. It will mean that other people will not have to make decisions on the person’s behalf without knowing what that person’s real feelings and wishes would be. It reduces the chance of confusion and conflict when others are making decisions about a person’s care. It means that the patient and the people close to them can feel comfortable and reassured that there will be a common and calm approach to their care toward the 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?

Step 1: Incorporate advance care planning as part of routine care of patients/residents
Step 2: Assess capacity of patient/resident to appoint a representative and complete an advance care plan
Step 3: Support discussion and documentation of advance care plan
Step 4: Apply the patient’s/resident’s wishes to medical care
Step 5: Review plan regularly or when health status changes significantly

IMPORTANT: Discuss ACP with the patients or residents during an ordinary consultation (opportunistic) or as part of health assessments.

Templates to complete ACP

1. Statement of Values and Wishes (completed by the patient) Statement of Values and Wishes (Patient)
2. Statement of Values and Wishes (completed for the patient) Statement of Values and Wishes (completed for the patient)
3. Record of ACP discussion (for RACFs to complete) Record of ACP discussions

Links

• Sydney South West Area Health Service: My Wish SSWAHS My Wish
• The Royal Australian College of General Practitioners has guidelines on Advance Care Planning
• New South Wales Government- Attorney General’s Department Capacity Toolkit - Information for government and community workers, professionals, families and carers in NSW. This has a section on Health including using their terminology Advanced Care Directives. Phone 02 8688 7507 or email diversity_services@agd.nsw.gov.au
• The Advance Care Directives Association also has its own website and a book ‘My Health, My Future, My Choice’ can be purchased
• The Benevolent Society developed a booklet that is no longer in print but can be downloaded titled ‘Your Future Starts Now - Guide for the over 50s’ -  (search for Advance Care Planning on their website)