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Advance care planning

Advance care planning process |    Substitute decision-making |    Advance care planning resources

This overview of advance care planning is from a clinical perspective. 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 to 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

Advance care planning process

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.

Step 1 |    Step 2 |    Step 3 |    Step 4 |    Step 5 |    Step 6

Step 1 – Identify

It is important to identify individuals who are most likely to benefit from advance care planning in order to commence care planning as early as possible. 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 with early identification of patients who may benefit from advance care planning. The ACP Quick Guide will be available in late October 2017.

Step 2 – Assess

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 includes an assessment of decision-making capacity.

Step 3 – Discuss

Initiate discussions with the person, as well as their substitute decision-maker(s), family and friends—where appropriate, and with consent of the patient. 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.

Step 4 – Plan

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 formal documentation of their preferences.

Advance care planning documents patients may choose to complete include:

  • Advance health directive—a legal document which allows you to give instructions about your future healthcare, and appoint an enduring power of attorney. It comes into effect if you have 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 your behalf when you have impaired capacity.
  • Statement of Choices—focuses on wishes, values and beliefs. It is a document in use in some Queensland hospitals, residential aged care facilities and GP clinics to support advance care planning conversations, but does not act as a substitute decision-maker or as consent.
  • Advance care planning documentation initiated by medical officers includes the Acute Resuscitation Plan (ARP). This is a clinical form that guides conversations between medical officers, adult patients and their substitute decision-maker(s), carers and family members about appropriate resuscitation planning, such as whether cardiopulmonary resuscitation (CPR) should be performed. An ARP form should be completed where it is reasonably expected than an adult patient (18 years and over) may suffer an acute deterioration or critical event (for example, a cardiac or respiratory arrest) in the foreseeable future and require resuscitation planning.

Note: completion of any documentation by a patient is entirely voluntary.

Step 5 – Coordinate

Coordination of care involves ensuring anything discussed or recorded in the context of advance care planning is implemented at the time a patient needs and 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.

Step 6 – Review

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 implies that 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. A number of consultations may be necessary. A multidisciplinary approach will ensure the unique, evolving needs of the individual, their substitute decision-maker(s), carers and family members will be addressed.

Queensland Health has developed a two page summary document of the Six Step ACP Process. This will be available in late October 2017.

Substitute decision-making

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Advance care planning resources

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Last updated: 3 August 2016

Office of Advance Care Planning

The Office of Advance Care Planning is funded by the Queensland Department of Health and can provide assistance with advance care planning information and resources for patients, carers, family members and health professionals.

Contact

Office of Advance Care Planning
Metro South Health
PO Box 72, Corinda Qld 4075
Phone: 1300 007 227
Fax: (07) 3710 2291
Email: acp@health.qld.gov.au

Decision Assist Phone Advisory Line

Decision Assist’s national telephone advisory service for aged care staff and General Practitioners for advice about advance care planning (8am - 8pm) and palliative care (24/7).

Phone: 1300 668 908