Advance care planning
This overview of advance care planning summarises content from the Queensland Health Advance Care Planning Clinical Guidelines. For information on advance care planning for patients, carers and family members, please visit the Queensland Government website.
Advance care planning is a person-centred process of planning for future health and personal care that reflects the person's goals, values, beliefs and preferences.
A collaborative and coordinated approach to the process of advance care planning establishes an understanding of the person's treatment and care goals in order to assist health professionals to better meet their needs.
Effective advance care planning involves ongoing communication between the person, those closest to them, and a multidisciplinary healthcare team to optimise the person's current treatment, care and quality of life.
Advance care planning can be carried out at any time and will be driven by the person's care needs and their willingness to participate. It is an iterative process and should be integrated into clinical practice and routine care. Regular review ensures plans remain consistent with the person's values, beliefs and preferences for health and personal care.
Advance care planning led by clinicians is usually undertaken within a health or aged care setting after a person has been diagnosed with a life-limiting condition. It requires respect for the individual and their autonomy.
Advance care planning can include:
- assessing the person's current condition and likely prognosis
- establishing the person's health and personal goals, values and preferences
- discussing current and future treatment and personal care options
- identifying the person's decision-makers for a time when they might lack capacity for decision-making
- documenting treatment and care plans and ensuring they are appropriately communicated and available when needed
- assisting the person to formally document their wishes if they choose to do so
- coordinating treatment and care to reflect the person's goals, values and preferences
- medical officers documenting clinical recommendations regarding resuscitation
- providing copies of formal documentation to substitute decision-maker(s), carers, family, GP and any other healthcare providers as appropriate
- reviewing decisions
A six step process for clinicians has been developed for carrying out advance care planning with patients. This process is not a single event—it is iterative and dynamic, and can evolve over time. Steps may need to be revisited, and how each step is implemented may vary depending on the person's needs, circumstances and the clinical environment and context.
A two page summary of the Six Step ACP Process is also available.
Any person can participate in advance care planning, even if they are healthy and otherwise well. However, there are key groups within the general population who may be broadly identified as benefiting from early advance care planning. This includes people of any age who:
- are diagnosed with a life-limiting illness or disability
- have multiple comorbidities and are at risk of deterioration
- have early and/or mild cognitive impairment
- manifest general indicators of frailty
- are living with chronic progressive deterioration of disease
- are approaching the end of their life
Queensland Health has developed a multidisciplinary ACP Quick Guide to support clinicians to identify patients who may benefit from advance care planning.
Proactive assessment of medical and psychosocial factors in order to anticipate the person's needs can ensure appropriate and timely treatment, care and support is provided. This proactive focus optimises opportunities to provide care that is consistent with an individual’s goals, values, beliefs and preferences and can include an assessment of the person’s decision-making capacity.
Initiate discussions with the person, as well as their substitute decision-maker(s), family and friends—where appropriate, and with their consent. Topics that may be covered include:
- the person's wishes, preferences or uncertainties in relation to their current or future treatment and care
- the emotions, beliefs or values that may be influencing the person's preferences and decisions
- the person's diagnosis, prognosis and questions about the goals of care
- family members, friends or other substitute decision-maker(s) that the person would like to be involved in decisions about their care
- resuscitation planning, which involves interventions that may be considered or undertaken in an emergency, such as CPR
- access and/or transition to other services, such as to palliative care or other community care services
- the benefits of advance care planning, such as when it may be helpful to make decisions in advance or appoint someone trusted to make decisions on the person's behalf
- the person's preferred place of care (and how this may affect treatment options available)
- the person's needs for religious, spiritual or other personal support
- wishes in relation to funerals, the handling of their body (including cultural needs), and their beliefs or values about organ or tissue donation.
Plan and identify future health and care needs by involving the person in decision-making to the greatest extent possible. This includes identifying and documenting the goals of care, as well as supporting patients to complete formally document of their preferences.
Advance care planning documents may include any of the following:
- Advance health directive—a legal document which allows a person to provide directions about future healthcare, and appoint an attorney for health and personal matters. Advance health directives activate only when a person has impaired capacity.
- Enduring power of attorney—a legal document giving another person(s) (substitute decision-maker) the authority to make personal (including healthcare) and/or financial decisions on their behalf when the person has impaired capacity.
- Statement of Choices—focuses on wishes, values and beliefs. It is a form used in some Queensland hospitals, residential aged care facilities and GP clinics to support advance care planning conversations. The Statement of choices can guide decision-making, but cannot be used in the same way as an advance health directive, as it is not a legal document.
- The Acute Resuscitation Plan (ARP) was implemented in Queensland Health facilities in 2009 as a statewide form to replace Not for Resuscitation Orders. The ARP is a medical order signed by the most senior doctor available and is designed to provide clinical direction in the event of acute deterioration. The ARP records resuscitation planning outcomes, following discussion with the patient or their substitute decision-maker (if the patient lacks capacity), and other members of the multidisciplinary team.
Note: completion of an advance health directive, enduring power of attorney or Statement of Choices by a patient is entirely voluntary.
Find an advance care planning document comparison table aimed at patients, carers and family members.
Coordination of care involves ensuring anything discussed or recorded in the context of advance care planning is implemented at the time a patient needs it and is carried out according to individual preferences. Best practice advance care planning is most appropriately coordinated by a multidisciplinary team of health professionals who address the person’s individual physical, emotional, psychological, social, practical, cultural and spiritual needs.
Advance care planning should be reviewed by the multidisciplinary team regularly to ensure currency, consistency and appropriateness with the person's evolving circumstances, needs, goals and preferences. The iterative nature of advance care planning often means it can take time for people to gather and process information, talk to their substitute decision-maker(s), carers and family members, and carry out relevant actions.
Find information on:
- Guardianship overview
- Statutory health attorney overview
- Guardianship and Administration Act 2000
- Powers of Attorney Act 1998
- Queensland Health’s End-of-life care: Guidelines for decision-making about withholding and withdrawing life-sustaining measures from adult patients
Find clinical tools and information to support advance care planning:
- Queensland Government information about advance care planning for patients, carers and family
- Queensland Health Advance Care Planning Clinical Guidelines
- My Health Record, an Australian Government initiative, allows people to upload advance care planning documents so that healthcare providers can access them from anywhere at any time.
- Advance care planning in general practice: Use of MBS Items—describes how MBS Item numbers may be used by GPs for advance care planning, where clinically appropriate
- palliAGED Developing Communication Skills –provides information on how to develop communication skills
- End-of-life law in Australia—information provided by Queensland University of Technology.
- Advance Care Planning Australia –information and resources about advance care planning
- Decision Assist—a national program providing education, resources and advisory services to support aged care staff and general practitioners in palliative care and advance care planning
- Advance eLearning offers a range of learning options for general practice nurses to develop their knowledge of, and skills in using, screening tools to support the provision of palliative care and advance care planning in everyday general practice.
- Dying to Talk discussion starter, card game and Aboriginal and Torres Strait Islander-specific resources
- ACPTalk—provides information for health professionals conducting advance care planning with people from different religious and cultural backgrounds
- MyValues—allows consumers to create a values profile
- Life Circle—information and resources for consumers.
The information provided on these pages is general in nature and is not intended as legal advice. Advance care planning issues will often be complex—you need to consider individual circumstances, and sometimes the level of detail will mean further advice is required. If you are in any doubt please seek legal advice.