Advance care planning
GPs develop ongoing and trusted relationships with their patients and are well positioned to initiate and promote advance care planning.
Advance care planning involves making a plan for future health and personal care should a person lose their decision-making capacity. It allows patients to express preferences to inform future medical treatment. It can also include provisions for palliative and end-of-life care. All adults should consider making advance care plans.
Advance care planning is the embodiment of person-centred health care and a response to the challenges that an ageing population and modern health care present. It allows health professionals to understand and respect a person’s preferences.
Advance care planning includes:
- expressing personal values and preferences for treatment and care through conversations with family, friends and health practitioners
- documenting these values and preferences in a document called an advance care directive (ACD)
- appointing a medical treatment decision-maker.
In Victoria, an ACD is the only legally recognised document in which a person can record their medical treatment preferences. To be valid, it must comply with the formal requirements set out in the Medical Treatment Planning and Decisions Act 2016. Find the advance care directive form, and instructions for completing it, here.
Advance care planning is relevant for all adults but should be prioritised for those who:
- are older
- have a chronic illness
- have multiple diseases
- have an early cognitive impairment
- are approaching end of life
For consumer information about advance care planning and palliative care, see our Older Adults page.
Improving advance care planning
We help GPs and primary health care providers incorporate advance care planning as part of usual practice, so that conversations take place while people are relatively well and able to take part in discussions.
Advance care planning can be introduced in general practice through:
- usual assessments and care planning such as the 75+ Health Assessment and chronic disease management planning
- routine consultations with a patient who has a chronic illness, is at risk of losing capacity, is in an aged care facility, or has just received a significant diagnosis
- follow-up consultations after a hospital admission.
Guide: Roles and responsibilities in advance care planning
We developed and implemented this resource with GPs and representatives from aged care, hospitals, district nursing, community health and medical deputising (locum) services. The Victorian Department of Health and Human Services funded the project.
The video above is a great introduction.
- describes how advance care planning can be undertaken across different health and care settings
- highlights the importance of relationships between individuals, their families/carers and health professionals, as well as between community organisations, health care organisations and individual health professionals
- summarises the roles that different people and organisations can play in the advance care planning process
- provides tips on how to systematically incorporate advance care planning in a practice or organisation.
- establishing robust systems so that your organisation can have the conversation
- ensuring you have an evidence-based and quality-focused approach to have the conversation
- increasing workforce capability to have the conversation
- enabling the person you are caring for to have the conversation.
Available to download
- Roles and responsibilities in advance care planning (full booklet)
- Advance care planning in general practice
- Advance care planning in residential aged care
- Advance care planning in hospitals
- Advance care planning in medical deputising (locum) services
- Advance care planning in domiciliary nursing services
- Advance care planning in community health
- Primary Health Network role in advance care planning
Medicare Benefits Schedule (MBS) item numbers
For information about which MBS items can be used for advance care planning, and tips on how to systematically include advance care planning as part of routine care, visit MBS Online or HealthPathways Melbourne.
Download the tip sheet: Make advance care planning part of routine care – MBS items
Changes to medical decision-making laws
Changes from March 2018 to the Medical Treatment Planning and Decisions Act 2016 (Vic) are:
- In the event of a patient not having decision-making capacity, medical practitioners will be obliged to make reasonable efforts to locate an Advance Care Directive and the patient’s Medical Treatment Decision Maker.
- Patients will be able to refuse treatment for conditions they do not currently have.
Find the Advance Care Directive form, and instructions for completing it, at this health.vic page.
- Visit our YouTube channel for past webinars.
- Deferred care session 3: chronic disease management, healthy ageing and palliative care (27 September 2022) (Advance care planning commences at 1:00:35)
- Advance Care Planning Australia and The Advance Project also run education events and offer online training.
- Visit our YouTube channel for past webinars.
These resources will help you and your patients understand and get the most out of the advance care planning process.
- ACP patient flyers: Who will make medical decisions for you if you can’t? These resources are designed to help patients start thinking about future health decisions and talk to those close to them about their wishes. Download the free resources, in 8 community languages, or complete the order form for hard copies.
- My Health Record: Patients can upload their advance care planning documents to My Health Record (a secure online summary of patient health information). Patients can also add the names and contact details of their nominated decision-makers.This fact sheet has information about uploading documents to My Health Record.
- Getting started guide: Advance Care Planning Australia
For general practice resources, including guidelines, advisory services, and information for people who lack capacity for ACP, visit HealthPathways Melbourne.
- Our quality improvement activities can help general practices to improve team knowledge and increase advance care planning for priority patients.
- The Advance Care Planning Improvement Toolkit, developed by Advance Care Planning Australia, aims to support the uptake and quality of advance care planning and advance care directives across Australia, ensuring that more people have choice and control over their future treatment decisions.