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Practice guides and tools

Advance Care Planning

The RACGP believes that Advance Care Planning should be incorporated into routine general practice

GPs develop ongoing and trusted relationships with their patients and are well positioned to initiate and promote Advance Care Planning (ACP). ACP is the embodiment of person-centred healthcare and a response to the challenges that an ageing population and modern healthcare present. When a patient loses the ability to make decisions about their care (accounting for approximately one in four patients at the end of life1), ACP ensures that a patient's expressed wishes remain the focus of decisions made about their care. ACP has also been shown to both improve end of life care and patient and family satisfaction2.

Although state and territory government laws vary on ACP and Advance Health Directives, Advance Health Directives in some form are legally binding documents in every state/territory of Australia. It is worth GPs familiarising themselves with some of the forms used in their state or territory.

What is Advance Care Planning?

ACP is a process of reflection, discussion and communication that enables a person to plan for their future medical treatment and other care, for a time when they are not competent to make, or communicate, decisions for themselves. ACP is about person-centred care and is based on fundamental principles of self-determination, dignity and the avoidance of suffering3

ACP promotes the expression of a person's values, beliefs and life goals. In the event that a person is unable to express their preferences due to anticipated deteriorating health, an accident or sudden illness, these articulated values, beliefs and life goals, help guide future care, including how decisions are made and by whom.

Although often about end-of-life care (the last 12 months) or terminal care (the last days to weeks of life), ACP is a process that all patients, and especially those who are at risk of deterioration in health, can benefit from.  A person may also wish to complete an advance care plan for other reasons (for example, there may be some treatment the patient would never wish to receive) or simply for peace of mind in case of unexpected illness or injury.

ACP will often lead to the completion of an Advance Care Directive (ACD). An Advance Care Directive is a written document, intended to apply to future periods of impaired decision-making capacity, which provides a legal means for a competent adult to instruct a Substitute Decision Maker and/or to record preferences for future health and personal care. ACDs are not clinical care or treatment plans, but clinical care or treatment plans can and should be informed by ACDs. Although a completed ACD is desirable for the purposes of ACP, the discussions that are central to ACP are valuable in their own right. It is important to note that verbally communicated instructions and values also hold weight.

RACGP Advance Care Planning position statement

Disclaimer: The RACGP provides these links for information proposes. It is not responsible for the content of these websites.

References

  1. Maria J. Silveira, Scott Y.H. Kim, and Kenneth M. Langa. Advance Directives and Outcomes of Surrogate Decision Making before Death. N Engl J Med 2010; 362:1211-1218April
  2. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010 Mar 23;340:c1345. doi: 10.1136/bmj.c1345
  3. The Clinical T, and Ethical Principal Committee, of the Australian Health Ministers' Advisory Council (AHMAC). A National Framework for Advance Care Directives. Consultation Companion Guide for the Draft Framework. Draft ed. Canberra: AHMAC; 2010.

New South Wales

Enduring Guardian/Power of Attorney

NSW Appointing an Enduring Guardian Fact Sheet

NSW Enduring Guardianship Form

NSW Enduring Power of Attorney Form (Also Available from the NSW Guardianship Tribunal web site)

Advance Health Directives

NSW Advance Health Care Directive Fact Sheet

NSW Advance Health Care Directive Form

NSW Advance Health Care Directive Form - Short Version

ACP Documents for Gay, Lesbian, Bisexual, Transgender and Intersex people

Advance Health Care Directive - Short Version - GLBTI

'respect my decisions: ITS MY RIGHT!' a Guide to Advance End-of-Life Care Planning for GLBTI People

ACP Documents For Use in Residential Aged Care Facilities

NSW Enduring Guardianship Form (for use in residential aged care facilities)

NSW Advance Health Care Directive (for use in residential aged care facilities)

NSW - Fact sheets: Advance Health Care Directive and Appointing an Enduring Guardian (for use in residential aged care facilitates)

Summary Sheet - Advance Health Care Directive (for resident's medical records in residential aged care facilities)

Statement From Person Responsible (for resident's medical records in residential aged care facilities)

Relevant legislation

Guardianship Act 1987

Websites

www.planningaheadtools.com.au/part/7/10/43
www.scu.edu.au/aslarc/index.php/8/
http://advancecareplanning.org.au/resources/new-south-wales

Australian Capital Territory

Enduring Power of Attorney

Enduring Power of Attorney form

Public Advocate of the ACT- Enduring Power of Attorney

Advance Care Directives and information

See Advance care planning Australia for ACT-specific resources including:

Advance care plan competent person
Health Directive
Advance Care Plan Incompetent Person
Australian Capital Territory Information Booklet and leaflet

Legislation

Powers of Attorney Act 2006

Website

http://advancecareplanning.org.au/resources/australian-capital-territory/

Victoria

Advance Care Directives and information

See Advance care planning Australia for Victoria-specific resources including:

Medical Enduring Power of Attorney (MEPOA)
Vic Advance Care Plan - Competent Person
Vic Advance Care Plan - Non Competent Person
VIC RPC Booklet
Victorian Information Booklet (Italian)
Victorian Information Booklet (Greek)
Victorian Information leaflet

Legislation

Medical Treatment Act 1988, Guardianship and administration act 1986 and the Mental health Act 1986:

www.legislation.vic.gov.au/

Website

http://advancecareplanning.org.au/resources/victoria/

South Australia

Advance Care Directives and information

See Advance care planning Australia for South Australia-specific resources including:

SA Contact Information and Anticipatory Direction (Enduring Power of Attorney)
SA Statement of Choices
SA Statement of Choices - Aged Care
SA Statement of Choices for people not having legal capacity
South Australia Information Booklet
South Australia Information Leaflet

Legislation

Consent to Medical Treatment and Palliative Care Act 1995

Website

http://advancecareplanning.org.au/resources/south-australia/

Tasmania

Enduring Powers of Attorney and other information

See Advance care planning Australia for Tasmania-specific resources including:

TAS Enduring Guardianship Info
TAS Enduring Guardianship Form
Tasmania Information booklet and leaflet

Advance Care Directive

www.tas.palliativecare.org.au/Portals/58/ACD_2012-07-17.pdf

Legislation

Guardianship and Administration Act 1995

Websites

www.health.wa.gov.au/advancehealthdirective/home/
http://advancecareplanning.org.au/resources/tasmania/

The Royal Australian College of General Practitioners

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