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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 and aged care 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.

https://www.youtube.com/watch?v=HZRwGxJ_1ug
Advance Care Planning: Roles and Responsibilities
  • 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.

    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

  • Medicare Benefits Schedule (MBS) item numbers

  • 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.

  • Education

  • Patient resources

    • 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 resource, available in eight community languages.
    • 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 (.pdf) has information about uploading documents to My Health Record.
    • Advance Care Planning Australia.