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.
Recommended guide: Roles and responsibilities in advance care planning (for providers)
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
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.
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.
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.
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.
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.
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.
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.
Policies and frameworks
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