What is advance care planning?
Advance care planning enables patients with decision-making capacity to plan for their future medical treatment and care for a time when they’re not able to make or communicate their wishes and decisions. It provides an opportunity for patients to plan for their possible future medical needs and discuss their personal values and healthcare preferences with their family, friends, GP and wider healthcare team.
For advance care plans to be effective, family members and treating clinicians need to know that they exist and be able to access them.
Why is it important?
Advance care planning can improve adherence to your patient’s preferences for ongoing and end-of-life care and reduce unwanted interventions and non-beneficial transfers to acute care facilities.
Having a care plan in place can also help to reduce anxiety and stress your patient and their family may be experiencing during illness and at end of life.
What is the GP’s role in advance care planning?
As a GP, you have ongoing and trusting relationships with your patients and are well-positioned to discuss future care options with them while they have decision-making capabilities.
An advance care planning conversation can fit in well as part of ongoing health assessments and when giving advice on healthcare options for any current diagnosis.
The RACGP aged care clinical guide (Silver Book) provides further information on the role GPs play in advance care planning, as well as guidance on establishing effective plans, assessing your patient’s decision-making capacity and more.
Appointment of a substitute medical decision-maker
Your patient can document the details of the person they appoint to make healthcare and treatment decisions on their behalf when they’re unable to make these decisions for themselves.
The appointed substitute medical decision-maker will need to document their agreement to undertaking this role.
Advance care directive
Creating an advance care directive is the best way for your patients to make their preferences known regarding the type of treatment they want should they enter a phase of life where they are no longer able to make their own decisions.
An advance care directive is considered a legal document and must be implemented as part of the clinical decision-making process for a patient who lacks the capacity to make decisions for themselves.
While it is preferable that patients complete the specific documents required by their state or territory, advance care directives do not need to be in a particular format or follow any formal requirements.
Goals-of-care document
These documents provide information about medical and non-medical goals of care in relation to a specific episode of care.
Goals of care are typically determined during an admission to hospital or at the beginning of a new treatment program. They are agreed upon by the patient along with their family, carers and healthcare providers.
Managing and sharing advance care planning documents
Once an advance care directive is created, copies of these documents should be shared and stored so that they are easily accessible when needed.
A copy should be stored as part of your patient’s local medical record. Your patient should provide copies to:
- any other healthcare providers involved in their care
- their family and friends
- their substitute medical decision-maker, if they have one.
Patients can upload a copy of their advance care directive to their My Health Record to make it available to all healthcare providers involved in their care. They can also add information about an advance care document custodian, which is a person or organisation chosen by the patient to hold copies of any advance care planning documents. Including these details enables other healthcare providers to contact the patient’s custodian where necessary to discuss the patient’s preferences for care.
Currently, there are no general practice CISs that have the functionality to upload a patient’s advance care planning documents to their My Health Record. When this functionality is available, GPs will be able to upload these documents on behalf of the patient with their consent.
Viewing a patient’s advance care planning documents in My Health Record
If your patient has uploaded advance care planning documents to their My Health Record, you can view these via your CIS so long as your practice is registered to use My Health Record.
In most CISs, advance care planning documents can be found in the ‘Documents’ list. Depending on which CIS you use, you may need to adjust certain filters to ensure the required documents are showing. Some clinical CISs will feature a flag indicating that your patient’s My Health Record includes advance care planning information.
If your CIS does not provide access to My Health Record, you can use the National Provider Portal to access your patient’s Health Record Overview. This will indicate if advance care planning information has been added.
Rules and regulations
Advance care planning may result in your patient appointing a substitute medical decision-maker, creating a written values statement regarding their goals of care or developing a specific and instructional advance care directive.
The rules regarding advance care directives and appointing substitute medical decision makers differ between states and territories. You can find further, more detailed information about these rules on the Advance Care Planning Australia website.
For more information regarding how consumers can upload various documents and information to their own My Health Record, visit The Agency’s website here.