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

What is Advance Care Planning?

The Advance Care Planning page from the ELDAC Care Model explains the purpose and importance of advance care planning, when to initiate conversations, what substitute decision-makers are, and where to find more general guidance.

Conversations about advance care planning often lead to an advance care plan. These are different to Advance Care Directives. You can read more about the different between these documents in the Advance Care Directives section of the End of Life Law Toolkit.

ELDAC supports documentation of advance care planning through use of an Advance Care Directive.

What is my role as a primary care professional in advance care planning?

Advance care planning (ACP) supports person-centred care, ensuring that care aligns with the value, beliefs, goals and preferences of older people. Primary care clinicians are well placed to initiate and promote advance care planning due to their ongoing and trusted relationships with the older person. 

We want you to be equipped to:

  • Understand the importance of completing an Advance Care Directive, and your role and responsibilities as a health professional.
  • Confidently initiate advance care planning conversations when appropriate.
  • Consider and prepare for the different needs of older people within diverse population groups.
  • Inform yourself or be familiar with the legalities of Advance Care Directive in the State or Territory you practise in.
  • Support the older person and their families through the planning process, including having difficult conversations around death and dying, grief, and bereavement, and by providing clear information and resources.
  • Appropriately store and share or transfer the Advance Care Directive with the older person, their families, carers, and other health professionals who may be a part of the care team. 

Advance Care Planning Position Statement

Royal Australian College of General Practitioners (RACGP)

This position statement advocates for the provision of ACP to be routine in general practice settings, identifying primary care practitioners as being well positioned to facilitate ACP discussions.

Roles and responsibilities in advance care planning

Advance Care Planning Australia (ACPA)

This webpage provides an overview on the responsibilities of health professionals in the provision of ACP, including considerations for diverse populations, legal and ethical considerations, and divergent responsibilities by healthcare setting.

Advance care planning for general practice

Advance Care Planning Australia (ACPA)

This webpage provides ACP information specific to general practice, including how to start the conversation, responsibilities of GPs, what MBS items may be used for ACP, and where to find further training and education.

Advance care planning as part of routine care (video)

Advance Care Planning Australia (ACPA)

This video provides an example of how to introduce ACP into a conversation as part of usual practice. It notes that planning occurs over time, and uses the example of a practice nurse introducing the idea, and a GP continuing the conversation. 

Factsheet for Health Professionals

Advance Care Planning Australia (ACPA)

This two-page factsheet provides information on the basics of ACP, including triggers for introducing ACP into conversation and tips for navigating what can be a difficult conversation.

A nurse introduces her patient to advance care planning (video)

Advance Care Planning Australia (ACPA)

This short video provides an example of how to introduce and speak about ACP in care.

Advance care planning for Aboriginal and Torres Strait Islander peoples

Advance Care Planning Australia (ACPA)

This webpage provides an overview of considerations for discussing ACP with Aboriginal and Torres Strait Islander peoples. It also provides direct resources for the older person to help navigate what palliative care means for them as an Aboriginal and Torres Strait Islander person.

Advance care planning for people who are LGBTIQ+

Advance Care Planning Australia (ACPA)

This article explores how to discuss ACP with LGBTIQ+ older persons, providing considerations for having conversations around ACP and death and dying, and practical tips to know.

Diverse Population Groups

ELDAC

ELDAC has compiled a series of information for diversity considerations in palliative care across population groups, including Aboriginal and Torres Strait Islander peoples, Care Leavers, Carers, Culturally and Linguistically Diverse, Financially or Socially Disadvantaged, Homeless, LGBTI+, Rural and Remote, Spirituality and Faith, and Veterans.

Caring for Diverse Populations 

ELDAC Primary Care Toolkit

The Older Person, Family and Carer Support section provides additional resources, further education and information on how to identify HealthPathways for diverse populations to support appropriate care.

Aboriginal and Torres Strait Islander Discussion Starter – Working Out What’s Right For You

Palliative Care Australia (PCA)

This resource has been developed to help guide conversations by health professionals with Aboriginal and Torres Strait Islander peoples and their community, to ensure care is person-centred and culturally appropriate. 

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.

End of Life Law in Australia: Advance Care Directives

Queensland University of Technology (QUT)

This webpage explores the law relating to Advance Care Directives (the result of ACP) both nationally, but also between each State and Territory.

Advance Care Planning and the Law

Advance Care Planning Australia (ACPA)

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 (ACPA)

This website provides forms and requirements for writing Advance Care Directives and appointing substitute decision-makers in your area.

Digital Tools 

ELDAC Primary Care Toolkit

This section of the Toolkit provides an overview of the digital tools available to support care delivery, and includes a summary of HealthPathways as a decision-making support resource and local referral guide.

Caring for Diverse Populations 

ELDAC Primary Care Toolkit

This section of the Toolkit provides a summary of resources on palliative and end-of-life care to provide to the older person, their family and carer(s) to support them.

Digital Tools 

ELDAC Primary Care Toolkit

This section of the Toolkit provides an overview of the digital tools available to support care delivery, and includes a summary of My Health Record as an information-sharing tool to help coordinate the care of the older person among members of the care team.

Accessing ACP documents 

Queensland Health

The ACP Tracker is a local tool to support QLD health professionals in accessing uploaded ACP documents and comments to support care delivery across care settings. This includes the Advance Care Directive, acute resuscitation plans, appointment records, radiology and pathology reports, treatment and discharge summaries, demographics and medication details.