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.
- 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
- 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
- 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.
Advance Care Directives and information
See Advance care planning Australia for Victoria-specific resources including:
Legal factsheets for individual and health professionals
Advance care directive for adults form
Appointment of medical treatment decision maker form
Appointment of support person
CALD resources in 15 languages
Medical Treatment Planning and Decisions Act 2016, Guardianship and administration act 1986 and the Mental health Act 1986: