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End-of-life care and advance care planning

GPs are well-placed to provide advance care planning, as well as end-of-life care for patients with advanced non-cancer illnesses.

Advance care planning is the process of planning your future health care in case you are unable to make or communicate your decisions. It can also include provisions for end-of-life care. All adults are encouraged to consider making advance care plans.

End-of-life care (palliative care) aims to improve the quality of life of patients with life-limiting illnesses. It is often associated with the care of people with cancer. But patients with non-cancer end-stage chronic or complex conditions also have significant needs that GPs can help to address.

We support GPs and other primary health care providers with education programs and resources. These include an end-of-life care quality improvement workbook, which practices can use independently, or with help from a dedicated NWMPHN relationship manager.

For consumer information about advance care planning and end-of-life care, see our Older Adults page.

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: Roles and Responsibilities
  • 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

    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.

  • 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

    This matrix outlines education available for health care professionals in the region, in both advance care planning and end-of-life care.


These resources will help you and your patients understand and get the most out of the advance care planning process.

End-of-life care

The aim of end-of-life care, or palliative care, is to improve the quality of life of patients with an active, progressive disease that has little or no prospect of a cure.

Improving end-of-life care is an Australian Government priority as our population ages and chronic diseases become more prevalent (Australian Institute of Health and Welfare). Yet studies have shown GPs can lack confidence in providing end-of-life care for reasons including patient complexity, inadequate training and insufficient resources. Poor communication and inadequate links with specialist palliative care services have also been identified as barriers.
Watch this video of our community panel forum, ‘What does dying well look like?’

Improving end-of-life care

An estimated 60 to 70 per cent of Australians would prefer to die at home. GPs and other primary health care providers play an integral role in fulfilling these wishes, where possible. We work to support them by:

  • improving links between primary care professionals (GPs, practice nurses, residential aged care staff) and community and inpatient services palliative care services
  • co-ordinating access to resources for primary health care providers regarding palliative care services in the region
  • co-ordinating access to quality palliative care education for health care professionals in the region.
Watch this video from the ‘Palliative care: how, where and when to refer’ education session.