Primary Care - Clinical Action - Advance Care Planning
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Advance Care Planning

Advance care planning is a routine part of a person’s healthcare. Primary care clinicians are well placed to initiate and promote advance care planning due to their ongoing and trusted relationships with their patients. Advance care planning is a process of reflection, discussion and communication that enables an individual’s expressed wishes to remain the focus of decisions made about their medical treatment and other care. It often leads to the completion of advance care planning documents.

Advance Care Planning - ELDAC Care Model

Advance care planning supports person-centred care, ensuring that care aligns with the values, beliefs, goals and preferences of patients. There is an expectation that one’s wishes for medical care at the end of life will be respected even if progressive disease takes away decision-making capacity. If a person is no longer able to make decisions for themselves, their advance care plan guides their family and doctors in making treatment decisions. Ideally advance care planning should be undertaken when a patient is medically stable.

Prompts for beginning discussions around advance care planning conversations include:

  • when a person or family member asks about current or future treatment options and goals,
  • at agreed milestones, such as at 75+ health assessments, chronic disease planning assessments, when an older person receives their annual flu vaccination,
  • when there is a diagnosis of metastatic malignancy or end organ failure, indicating a poor prognosis,
  • when there is a diagnosis of early dementia or a disease which could result in loss of capacity,
  • if there is a change in condition, for example increased frequency of exacerbations, unplanned or unexpected admissions to hospital, etc.,
  • if the death of the person within the next twelve months would not be surprising to you,
  • if there are changes in care arrangements (for instance, admission to a residential aged care facility).

Royal Australian College of General Practitioners—Advance Care Planning Position Statement (607kb pdf) 

Advance Care Planning Australia—Roles and responsibilities in advance care planning

An Advance Care/Health Directive is a type of written advance care plan, recognised by common law or specific legislation and completed and signed by a competent adult. It can record the person’s preferences for future care, and appoint a substitute decision-maker to make decisions about health care and personal life management (Australian Health Ministers’ Advisory Council, 2011). Despite varied state and territory legislation and documentation, advance care directives in some form are legally binding documents in every state/territory of Australia.

The Royal Australian College of General Practitioners (RACGP) recommends that GPs familiarise themselves with the forms used in their state or territory.

Advance Care Planning

Royal Australian College of General Practitioners (RACGP)

This webpage provides information to support GPs incorporating advance care planning into routine general practice. It also provides state based practice guides and tools to support advance care planning in each state and territory.

Advance Care Planning and the Law

Advance Care Planning Australia

This webpage provides information on the legalities of advance care planning across Australia.

Advance Care Planning in Your State and Territory

Advance Care Planning Australia

This website provides forms and requirements for writing advance care directives and appointing substitute decision-makers in your area.

Advance Care Planning for General Practice

Advance Care Planning Australia

  • ACPA provides a one-page guide for clinicians working in general practice to support advance care planning. It includes common triggers for advance care planning, and strategies for initiating and structuring conversations.
  • ACPA also provides a general practice frequently asked questions factsheet (178kb pdf)

What is Advance Care Planning?

Advance Care Planning Australia
This webpage provides information about advance care planning for individuals and family.

Dying to Talk Discussion Starter

Palliative Care Australia
The Dying to Talk Discussion Starter provides guidance for patients to reflect on their values and preferences for end of life care. It supports patients to prepare for and initiate these discussions with family, friends and healthcare providers.

  • Practice nurse (registered and enrolled nurses)
  • General practitioner
  • Healthcare professionals

Advance eLearning Modules
The Advance Project

The Advance Project website provides a free toolkit of screening and assessment tools and a training package, specifically designed to support nurses in Australian general practices to work with GPs to initiate palliative care and advance care planning in everyday general practice.

Advance Care Planning Australia - Learning
Advance Care Planning Australia

This website provides a national eLearning hub to support aged care workers, health professionals and consumers learn more about advance care planning, addressing introductions, conversations, planning legal implications and more. Advance Care Planning Australia are curently reviewing the online learning modules.

A nurse introduces her patient to advance care planning

Advance Care Planning Australia
Video: Michael is living with a chronic disease. During a routine medical visit, his general practice nurse asks him if he has any other concerns. Michael is worried about his future care and the stress that it might place on his wife. His nurse talks him through the steps of advance care planning.

End of Life Law for Clinicians
Palliative Care Education and Training Collaborative

This training program for medical practitioners and students, nurses and allied and other health professionals focuses on the law relating to end of life decision-making. There are 11 modules.

eLearning for General Practitioners

The Advance Project

Advance is an eLearning module for general practitioners that is accredited by the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine. The eLearning module is specifically designed for general practitioners to support early identification and assessment of patients’ palliative and supportive care needs.

Advance Care Planning - Have the Conversation (2.6MB pdf)

AMA Victoria

The 9 modules linked below are a free training resource designed to support doctors to discuss end of life decision making with their patients. The aim of these resources is to encourage doctors to engage in advance care planning conversations with patients well before any diagnosis, when the patient is medically stable and thinking clearly. This emphasises a focus on patient-centred care and living well within the Victorian healthcare system.

Advance Care Planning Australia - Learning
Advance Care Planning Australia

This website provides a national eLearning hub to support aged care workers, health professionals and consumers learn more about advance care planning, addressing introductions, conversations, planning legal implications and more. Advance Care Planning Australia are curently reviewing the online learning modules.

A doctor and patient discuss advance care planning

Advance Care Planning Australia
Video: Michael, who is living with chronic disease, talks to his doctor about creating an advance care plan.

End of Life Law for Clinicians
Palliative Care Education and Training Collaborative

This training program for medical practitioners and students, nurses and allied and other health professionals focuses on the law relating to end of life decision-making. There are 11 modules.

Podcast Episode 3: Law at end-of-life

Law at End of Life

RACP
This episode features interviews with Prof Ben White and A/Prof Colin Gavaghan discussing law at the end of life. While the majority of decisions are reached without contention law in this field is complex, and varies by jurisdiction.

Talking about dying: How to begin honest conversations about what lies ahead
Royal College of Physicians

This report offers advice and support for any doctor on holding discussions with patients much earlier after the diagnosis of a progressive or terminal condition, including frailty.

Advance Care Planning: Roles and Responsibilities
North Western Melbourne Primary Health Network
This video guide is designed for health practitioners to provide information on how to include advance care planning in clinical interactions and organisational responsibility.

Discussing Choices - Indigenous Advance Care Plans - A Learning Resource
Palliative Care Australia

Discussing Choices – Indigenous Advance Care Plans – A Learning Resource acts as a culturally safe and practical case study for professional health, Aboriginal and community workers on ‘how to’ support and complete Advance Care Plans for end-of-life care in Indigenous communities.

Advance Care Planning Australia - Learning
Advance Care Planning Australia

This website provides a national eLearning hub to support aged care workers, health professionals and consumers learn more about advance care planning, addressing introductions, conversations, planning legal implications and more. Advance Care Planning Australia are curently reviewing the online learning modules.

Advance Care Directives
End of Life Directions in Aged Care (ELDAC)

This factsheet provides information on advance care directives.

End of Life Law for Clinicians
Palliative Care Education and Training Collaborative

This training program for medical practitioners and students, nurses and allied and other health professionals focuses on the law relating to end of life decision-making. There are 11 modules.

Substitute decision-making
End of Life Directions in Aged Care (ELDAC)

This factsheet provides information on substitute decision-making.

Barriers and facilitators for GPs in dementia advance care planning: A systematic integrative review (1.59MB pdf)

Tilburgs, B, Vernooij-Dassen, M, Koopmans, R, van Gennip, H, Engels, Y and Perry, M 2018, ‘Barriers and facilitators for GPs in dementia advance care planning: A systematic integrative review’, PLoS ONE, vol. 13, no. 6, pp. e0198535.