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.

The resource:

• 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.

Topics include:

• 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

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 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.

We run and promote ACP training and education during the year. To find out about education events subscribe to our newsletters or visit our events calendar.

• 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.

• 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.