Advance care planning helps a person, their families and carers to understand their values, attitudes, life goals and acceptable outcomes from health care which makes decision making easier and clearer when the person is unable to share their preferences. More than one in two Australians will be unable to make their own decisions about medical care at the end of their lives, yet only 15% of Australians have an Advance Care Directive[1]. Missing, ambiguous or inaccurate documentation of a person’s advance care planning preferences may lead to inappropriate or unwanted care for people at the end of life or undue stress and burden on family members.
Aged care workers and health professionals play a critical role in ensuring that people’s choices and preferences are understood and respected. Discussions regarding advance care planning should be seen as a usual part of care and a normal part of life. Preferably, these discussions should occur when a person is medically stable, is not under time pressure, and can be supported by their family, friends, and carer. It Is recommended that the person’s family, carer or nominated substitute decision maker is present for these discussions.
When to Discuss Advance Care Planning
Health care professionals and aged care workers can find opportunities to discuss advance care planning with their patients when:
- A person or family member asks about the patient’s current or future treatment options and goals
- They need to undergo a condition-related health assessment
- They are an older person receiving their annual flu vaccination
- There is a diagnosis of a metastatic malignancy or end-organ failure, indicating a poor prognosis
- There is a diagnosis of early dementia or a disease that could result in loss of capacity
- It is possible that their life will end within the next 12 months
- There are changes in care arrangements, for example, admission to a residential aged care facility
How Health Professionals and Aged Care Workers can Support Advance Care Planning
Health professionals and aged care workers are encouraged to have regular discussions about advance care planning and how it relates to the patient’s health conditions, treatment options and prognosis. The discussions should involve addressing any concerns with the patient’s capability, assessing the chances of them experiencing diminishing capacity and creating an Advance Care Plan. This involves filling out an Advance Care Directive form. An Advance Care Directive records a person’s specific wishes and preferences for future care, such as medical treatments they would accept or refuse if they had a life-threatening illness or injury. This will only be used when they do not have the capacity to decide for themselves or to communicate their wishes. It is recommended the Advance Care Directive be written and signed by them and a witness and be reviewed regularly.
Advance Care Planning documents can be uploaded to My Health Record to ensure they can be appropriately shared and transfered between health service providers.
To further support patients, health professionals can refer them to an advance care planning facilitator or contact the National Advance Care Planning Support Service.
For more information about advance care planning, please contact our End-of-life and Palliative Care Facilitator, Barbara Mossman at barbara.mossman@wentwest.com.au
Additional Resources
It is important to provide patients, their families, carers and substitute decision makers with clear information and resources about advance care planning. There are additional resources for health professionals, aged care workers and patients to refer to below.
Advance Care Planning Australia resources:
- Order or print support materials
- Translated resources
- Guidance on the use of Medicare Benefits Schedule Items
HealthPathways resources for health professionals in Western Sydney:
To access HealthPathways, please contact our HealthPathways team at healthpathways@wentwest.com.au
NSW Health:
- Information for health professionals
- Information for patients, families and carers
- Palliative care easy read resources
[1]White, Tilse, Wilson, Rosenman, Strub, Feeney and Silvester (2014), Internal Medicine Journal, Prevalence and predictors of advance directives in Australia, accessed from: https://nmsw.uq.edu.au/files/3657/White_et_al-2014-Internal_Medicine_Journal.pdf
23 March 2023