Advance care planning is increasingly being recognised as an important process for people to consider, across all stages of adult life.


Changes to medical decision-making laws

From 12 March 2018, changes to medical decision-making laws will take effect when the Medical Treatment Planning and Decisions Act 2016 (the Act) starts. Changes include:

  • 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 (ACD) and the patient's Medical Treatment Decision Maker (MTDM)
  • 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, on the Victorian Department of Health website


Supporting Advance Care Planning

Through our Advance Care Planning (ACP) program, NWMPHN supports health and care providers to incorporate advance care planning as part of usual practice, so that conversations take place while people are relatively well and able to participate in discussions. At the same time, we are supporting the community to communicate their future health care choices.


Roles and responsibilities in ACP - for providers

This resource was developed as part of a collaborative quality improvement (QI) project between June 2015 and March 2016.

The Department of Health and Human Services (DHHS) funded the project, through Networking Representatives from general practice, aged care, hospitals, district nursing, community health and medical deputising/locum services (MDS) worked closely with North Western Melbourne Primary Health Network (NWMPHN) to systematically implement ACP in each organisation as well as across all the of the partners involved.

Aims of the resource

  • To describe how ACP can be undertaken across different health and care settings
  • To highlight 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
  • To summarise the roles that different people and organisations can play in the ACP process and provide tips on how to systematically incorporate ACP within your organisation

Each section looks at how different health care settings can implement ACP

  • Establishing robust systems so that your organisation can have the conversation
  • Ensuring you have an evidence based and quality approach to have the conversation
  • Increasing workforce capability to have the conversation
  • Enabling the person you are caring for the have the conversation


Download the booklet

ACP in General Practice

ACP in Residential Aged Care

ACP in Hospitals

ACP in Medical Deputising (Locum) Services

ACP in Domiciliary Nursing Services

ACP in Community Health

Primary Health Network role in ACP

We are also working to improve the way ACP information is made available across health care settings, so that members of the community can communicate their future health care choices.

A range of links and resources are available below to support you in undertaking advance care planning with your patients/clients.

These include the Advance Care Planning Health Pathway, which provides relevant information including documents, forms and contacts at local hospitals to support ACP.


MBS item numbers and ACP

You can find information about which MBS items can be used for ACP, and tips on how to systematically include ACP as part of routine care in this brochure or visit HealthPathways Melbourne.


Education opportunities for Advance Care Planning and Palliative Care

You can find information about a range of educational opportunities for health professionals by downloading the education matrix below.

Download education matrix


Patient resources

These resources are designed to help you start thinking about future health decisions and to talk to those close to you about your thoughts. Who will make medical decisions for you if you can't? How will they know what you want?

Download the free resources below or complete the Order Form to order brochures.


My Health Record

My health record (MyHR) is a secure online summary of your patient’s health information. They can control what goes into it, and restrict who can access it. They can choose to share their health information with their doctors, hospitals and other healthcare providers. 

The Government is expanding MyHR for all Australians in 2018.

Your patients can upload their Advance Care Planning documents to their MyHR. They can also add the names of their decision makers so you can contact them if needed. 

See the fact sheet for information on how to upload documents to MyHR.

Watch these short videos below to inspire you to have the conversation about ACP.

What care would you want?

Taking care of dying time

What does dying well look like? Engaging our community

Introducing advance care planning


Further information about ACP

A range of resources and information are available via the Advance Care Planning Australia (ACPA) website and the Victorian Government Advance Care Planning website. These websites provide links to frequently asked questions, forms and templates, brochures, research and further information.

Advance Care Planning Pathway - HealthPathways Melbourne

The Advance Care Planning pathway for HealthPathways Melbourne is now live on the online portal. To access the site, request the username and password from the HealthPathways Melbourne team via email

Office of the Public Advocate

The Office of the Public Advocate (Victoria) website has useful information, available in different languages about:

  • Medical decision making
  • Making enduring powers of attorney
  • Accessing forms and publications.

You can also call the OPA Advice Service on 1300 309 337 (9am to 5pm Monday-Friday).

Advance Care Planning Australia (ACPA)

Resources and information for health professionals and community members are available via the Advance Care Planning Australia website.This website provides links to frequently asked questions, forms and templates, brochures, research and further information.

ACPA also provides education and training and resources and delivers on a wide range of projects and initiatives in collaboration with like organisations to support best practice advance care planning and to build its evidence base.

Australian Medical Association

The AMA Victoria Advance care planning resource for doctors is presented in nine modules to support doctors and other health professionals to:

  • have the conversation with patients about end-of-life decision making
  • engage patients in decisions about their care
  • help them to undertake advance care planning

CareSearch Palliative Care Knowledge Network

The Caresearch website includes ‘hubs’ for GPs, allied health, nurses and community members. Information relates to palliative care, including advance care planning and having end of life and difficult conversations.


Royal Australian College of General Practitioners

The Royal Australian College of General Practitioners (RACGP) released a Position Statement (.pdf, 607kb) in September 2012 that clarifies that advance care planning should be incorporated into routine general practice.

The RACGP Medical care of older persons in residential aged care facilities 4th edition (Silver Book) includes sections on advance care planning, palliative care and end of life care.

The RACGP website also provides links to information and resources specific to each state and territory.


Local hospital advance care planning programs

Hospitals in our region can provide information about ACP. Contact the relevant hospital or visit their website for more information.

Alfred Health
Contact or phone 03 9076 6642

bestCARE - St Vincent’s Hospital

Melbourne Health, Royal Melbourne Hospital

Northern Health, all campuses 
Contact or phone: 03 9495 3235

Peter MacCallum Cancer Centre

Western Health, all campuses
Contact or phone: 0423 043 926.


More information

Contact Jesse Osowicki on (03) 9347 1188 or email