Advance Care Planning

Advance care planning enables health professionals to work with individual patients to identify personal needs and preferences for care and treatment. This is especially important for stages in an individual’s life when they may no longer have physical or mental capacity.

What is advance care planning

Advance care planning (ACP) is an ongoing process. Therefore, it depends on cooperation among individuals, their families, care workers and health professionals alongside community organisations and health care organisations.

ACP includes:

  • Discussions about values and wishes of health treatments
  • Making an advance care directive
  • Appointing a medical treatment decision maker
  • Appointing a support person
  • Sharing the advance care directive with relevant people

Since March 2018, advance care directives have statutory recognition through the Medical Treatment Planning and Decision Act 2016

The Act ensures people living in Victoria have their wishes and decisions about medical treatment respected even if they lose capacity make such decisions. It is important health professionals are familiar with the Act and their responsibilities under the Act. For more details, refer to the Advance Care Planning Australia website

The role of health professionals

Western Victoria PHN is here to support health care professionals to include ACP as part of patient care. Health professionals have a key role in talking with patients about their values, future health goals and treatment preferences while they are still relatively well and able to participate.

As part of the ACP process, general practitioners and nursing staff in general practice are responsible for:

  • Identifying existing documents and/or Medical Treatment Decision Maker (MTDM) and accurately recording details
  • Providing patients with information about ACP
  • Discussing health issues, condition, treatment options, prognosis and ACP
  • Encouraging discussion with the patients’ MTDM and involve MTDM/family where possible and appropriate
  • Helping a patient document their Advance Care Directives (if required), checking draft documents and helping clarify wording or intentions
  • Recording discussions about ACP in medical software and ensuring others can access this information if needed
  • Storing copies of ACP-related documents, including Advance Care Directives (ACD) in medical records so they are accessible when needed
  • Sharing information about the patient’s ACD with others involved in their care (with patient consent) – such as hospital or specialists
  • Encouraging patients to give copies to anyone who may be involved in making decisions about their care and to upload copies of the ACD to their My Health Record
  • Ensuring information is available if care is needed after hours (for example, by a medical deputising service/locum service)
  • Regularly reviewing ACDs particularly if a patient’s situation changes
  • Activating (enacting) the ACD when needed including using ACDs to inform medical treatment and care decisions if the patient loses capacity.

Advance care planning support services in western Victoria

Other resources

Last modified: 7 February, 2020