End-of-life care and 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.

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.

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

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 different community languages, or complete the order form for hard copies.

• English
• Arabic
• Traditional Chinese
• Simplified Chinese
• Greek
• Italian
• Macedonian
• Turkish
• Vietnamese

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.

For more resources and information, including forms and templates, brochures, research and answers to frequently asked questions, see:

• Advance Care Planning Australia website (includes education and training)
• Advance care planning at health.vic
• Advance care planning pathway on HealthPathways Melbourne
• Office of the Public Advocate (Victoria) website (for information in different languages about medical decision-making and making enduring powers of attorney, and for access to forms and publications)
• CareSearch Palliative Care Knowledge Network website (includes ‘hubs’ for GPs, allied health practitioners, nurses and community members)
• RACGP’s position statement (clarifying how advance care planning should be incorporated into routine general practice) and links to information and resources about advance care planning, specific to each state and territory.

• National Palliative Care Strategy 2018
• Victoria’s End-of-life and palliative care framework 

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

• Department of Health – palliative care
• Palliative Care Victoria
• Palliative Care Australia
• HealthPathways Melbourne – clinical referral information
• North West Metropolitan Region Palliative Care Consortium
• Hammond Care
• CareSearch Palliative Care Knowledge Network
• Victorian Aboriginal Community Controlled Health Organisation (VACCHO) – palliative care project
• Program of Experience in the Palliative Approach
• Office of the Public Advocate
• Very Special Kids
• Victorian Paediatric Palliative Care Program – Royal Children’s Hospital
• Centre for Palliative Care
• Victorian Comprehensive Cancer Centre
• Australian Centre for Grief and Bereavement