Advance care planning and My Health Record

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 and GP, as well as their wider healthcare team.

For advance care plans to be effective, family members and treating clinicians need to know they exist and be able to access them.

Why is it important?

Advance care planning can improve your patient’s certainty and reduce their anxiety about the care they receive and can reduce their family members’ anxiety and stress during illness and at end of life.

It can also 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.

What is the GP’s role?

As a GP, you have ongoing and trusting relationships with your patients. You are well positioned to discuss future care when patients 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 advance care planning in general practice.

What can be included in advance care planning?

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, and specific information is available on the Advance Care Planning Australia website.

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 substitute medical decision-maker also needs 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’d want if they were 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’s preferable 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 would normally be determined during an admission to hospital or at the beginning of a new treatment program. They are agreed upon by the patient, their family and carers, and their 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 they’re 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, family and friends, and 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, 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 your patient’s custodian to discuss their preferences for care.

Currently, there are no general practice clinical information systems (CIS) 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 patient 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 if you are registered to use the My Health Record. In most CIS, advance care planning documents can be found in the documents list. Depending on which CIS you use, you may need to adjust the document filters to ensure the documents are showing. Some clinical CISs will feature a flag indicating your patient’s My Health Record includes advance care planning information.

If your CIS does not provide access to the 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.

Resources for GPs


Australian Digital Health Agency

Advance Care Planning Australia

Webinar recording – Advance care planning and My Health Record