Action 5.17 states

The health service organisation has processes to ensure that current advance care plans:

  1. Can be received from patients
  2. Are documented in the patient’s healthcare record

Intent

Patients with an advance care plan receive care in line with their plan if they lack capacity to participate in decision making.

Reflective questions

How does the health service organisation receive advance care plans from patients?

How does the health service organisation ensure that advance care plans are documented in the patient’s healthcare record and that care is provided in accordance with these plans?

Key task

Develop processes to receive, document and provide access to advance care plans.

Strategies for improvement

Hospitals

In this action, advance care planning refers to the process of preparing for likely clinical scenarios near the end of life. Advance care planning can help to ensure that patients’ preferences are known if they are no longer able to speak for themselves, and can reduce the likelihood of unwanted or inappropriate treatment.

The outcome of advance care planning processes may be the documentation of an advance care plan, which may include a formal advance care directive and nomination of a substitute decision-maker. Legislation and policy governing the documentation of advance care directives and nomination of substitute decision-makers vary in each state and territory. The Advance Care Planning Australia website includes information for consumers and clinicians, and links to state and territory resources to guide advance care planning and the documentation of advance care directives.

Develop standardised processes for:

  • Determining whether a patient has a pre-existing and up-to-date advance care plan and, if so, ensuring that a copy is available in the healthcare record
  • Ensuring that advance care plans are readily accessible to clinicians involved in providing care to patients
  • Providing access to documented advance care plans in all areas where care is provided, and in emergency situations.

Advance care plans can be documented on paper or stored electronically in the patient’s digital healthcare record.

Evaluate processes for receiving and acting on advance care plans by using the reportable event system to investigate failures to provide care in accordance with a patient’s advance care plan. Consider adding items relating to advance care planning to the statewide or organisation-wide incident management and investigation systems. For example, in South Australia, items relating to advance care planning have been added to statewide incident reporting systems, including:

  • Delay or failure in obtaining the advance care plan
  • Missing, inadequate or illegible documentation of the advance care plan
  • Communication inadequate or failed between clinicians
  • Communication inadequate or failed between substitute decision-maker/family/carers and clinicians
  • Patient incorrectly identified or advance care plan does not match patient
  • Substitute decision-maker contact delayed or not attempted
  • Dispute between clinicians
  • Dispute between substitute decision-maker/family/carers and clinicians
  • Advance care plan ignored, not followed or not used
  • Planned treatment option unavailable.

Day Procedure Services

In this action, advance care planning refers to the process of preparing for likely clinical scenarios near the end of life. Advance care planning can help to ensure that patients’ preferences are known if they are no longer able to speak for themselves, and can reduce the likelihood of unwanted or inappropriate treatment.

The outcome of advance care planning processes may be the documentation of an advance care plan, which may include a formal advance care directive and nomination of a substitute decision-maker. Legislation and policy governing the documentation of advance care directives and nomination of substitute decision-makers vary in each state and territory. The Advance Care Planning Australia website includes information for consumers and clinicians, and links to state and territory resources to guide advance care planning and the documentation of advance care directives.

Ensuring access to a patient’s advance care plan means that, if a serious complication arises and the patient requires transfer for ongoing care, the advance care plan will be available to direct care if the patient is no longer able to speak for themselves.

Develop standardised processes for:

  • Determining whether a patient has a pre-existing and up-to-date advance care plan during the pre-admission screening and admission process, and, if so, ensuring that a copy is available in the healthcare record
  • Ensuring that advance care plans are readily available in the healthcare record
  • Providing access to documented advance care plans if care is transferred to another service and in emergency situations.

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the requirements for documenting advance care plans in the patient’s healthcare record
  • Reviews of the use of advance care plans
  • Audit results of healthcare records for documentation of advance care plans
  • Reports of incidents of noncompliance with the use of advance care plans (for example, when advance care plans were unavailable, illegible or not used to guide care when they should have been) and actions taken to deal with these incidents.

MPS & Small Hospitals

In this action, advance care planning refers to the process of preparing for likely clinical scenarios near the end of life. Advance care planning can help to ensure that patients’ preferences are known if they are no longer able to speak for themselves, and can reduce the likelihood of unwanted or inappropriate treatment.

The outcome of advance care planning processes may be the documentation of an advance care plan, which may include a formal advance care directive and nomination of a substitute decision-maker. Legislation and policy governing the documentation of advance care directives and nomination of substitute decision-makers vary in each state and territory. The Advance Care Planning Australia website includes information for consumers and clinicians, and links to state and territory resources to guide advance care planning and the documentation of advance care directives.

Develop standardised processes for:

  • Determining whether a patient has a pre-existing and up-to-date advance care plan and, if so, ensuring that a copy is available in the healthcare record
  • Ensuring that advance care plans are readily accessible to clinicians involved in providing care to patients
  • Providing access to documented advance care plans in all areas where care is provided, and in emergency situations.

Advance care plans can be documented on paper or stored electronically in the patient’s digital healthcare record.

Evaluate processes for receiving and acting on advance care plans by using the reportable event system to investigate failures to provide care in accordance with a patient’s advance care plan. Consider adding items relating to advance care planning to the statewide or organisation-wide incident management and investigation systems. For example, in South Australia, items relating to advance care planning have been added to statewide incident reporting systems, including:

  • Delay or failure in obtaining the advance care plan
  • Missing, inadequate or illegible documentation of the advance care plan
  • Communication inadequate or failed between clinicians
  • Communication inadequate or failed between substitute decision-maker/family/carers and clinicians
  • Patient incorrectly identified or advance care plan does not match patient
  • Substitute decision-maker contact delayed or not attempted
  • Dispute between clinicians
  • Dispute between substitute decision-maker/family/carers and clinicians
  • Advance care plan ignored, not followed or not used
  • Planned treatment option unavailable.

Hospitals

In this action, advance care planning refers to the process of preparing for likely clinical scenarios near the end of life. Advance care planning can help to ensure that patients’ preferences are known if they are no longer able to speak for themselves, and can reduce the likelihood of unwanted or inappropriate treatment.

The outcome of advance care planning processes may be the documentation of an advance care plan, which may include a formal advance care directive and nomination of a substitute decision-maker. Legislation and policy governing the documentation of advance care directives and nomination of substitute decision-makers vary in each state and territory. The Advance Care Planning Australia website includes information for consumers and clinicians, and links to state and territory resources to guide advance care planning and the documentation of advance care directives.

Develop standardised processes for:

  • Determining whether a patient has a pre-existing and up-to-date advance care plan and, if so, ensuring that a copy is available in the healthcare record
  • Ensuring that advance care plans are readily accessible to clinicians involved in providing care to patients
  • Providing access to documented advance care plans in all areas where care is provided, and in emergency situations.

Advance care plans can be documented on paper or stored electronically in the patient’s digital healthcare record.

Evaluate processes for receiving and acting on advance care plans by using the reportable event system to investigate failures to provide care in accordance with a patient’s advance care plan. Consider adding items relating to advance care planning to the statewide or organisation-wide incident management and investigation systems. For example, in South Australia, items relating to advance care planning have been added to statewide incident reporting systems, including:

  • Delay or failure in obtaining the advance care plan
  • Missing, inadequate or illegible documentation of the advance care plan
  • Communication inadequate or failed between clinicians
  • Communication inadequate or failed between substitute decision-maker/family/carers and clinicians
  • Patient incorrectly identified or advance care plan does not match patient
  • Substitute decision-maker contact delayed or not attempted
  • Dispute between clinicians
  • Dispute between substitute decision-maker/family/carers and clinicians
  • Advance care plan ignored, not followed or not used
  • Planned treatment option unavailable.

Day Procedure Services

In this action, advance care planning refers to the process of preparing for likely clinical scenarios near the end of life. Advance care planning can help to ensure that patients’ preferences are known if they are no longer able to speak for themselves, and can reduce the likelihood of unwanted or inappropriate treatment.

The outcome of advance care planning processes may be the documentation of an advance care plan, which may include a formal advance care directive and nomination of a substitute decision-maker. Legislation and policy governing the documentation of advance care directives and nomination of substitute decision-makers vary in each state and territory. The Advance Care Planning Australia website includes information for consumers and clinicians, and links to state and territory resources to guide advance care planning and the documentation of advance care directives.

Ensuring access to a patient’s advance care plan means that, if a serious complication arises and the patient requires transfer for ongoing care, the advance care plan will be available to direct care if the patient is no longer able to speak for themselves.

Develop standardised processes for:

  • Determining whether a patient has a pre-existing and up-to-date advance care plan during the pre-admission screening and admission process, and, if so, ensuring that a copy is available in the healthcare record
  • Ensuring that advance care plans are readily available in the healthcare record
  • Providing access to documented advance care plans if care is transferred to another service and in emergency situations.

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the requirements for documenting advance care plans in the patient’s healthcare record
  • Reviews of the use of advance care plans
  • Audit results of healthcare records for documentation of advance care plans
  • Reports of incidents of noncompliance with the use of advance care plans (for example, when advance care plans were unavailable, illegible or not used to guide care when they should have been) and actions taken to deal with these incidents.

MPS & Small Hospitals

In this action, advance care planning refers to the process of preparing for likely clinical scenarios near the end of life. Advance care planning can help to ensure that patients’ preferences are known if they are no longer able to speak for themselves, and can reduce the likelihood of unwanted or inappropriate treatment.

The outcome of advance care planning processes may be the documentation of an advance care plan, which may include a formal advance care directive and nomination of a substitute decision-maker. Legislation and policy governing the documentation of advance care directives and nomination of substitute decision-makers vary in each state and territory. The Advance Care Planning Australia website includes information for consumers and clinicians, and links to state and territory resources to guide advance care planning and the documentation of advance care directives.

Develop standardised processes for:

  • Determining whether a patient has a pre-existing and up-to-date advance care plan and, if so, ensuring that a copy is available in the healthcare record
  • Ensuring that advance care plans are readily accessible to clinicians involved in providing care to patients
  • Providing access to documented advance care plans in all areas where care is provided, and in emergency situations.

Advance care plans can be documented on paper or stored electronically in the patient’s digital healthcare record.

Evaluate processes for receiving and acting on advance care plans by using the reportable event system to investigate failures to provide care in accordance with a patient’s advance care plan. Consider adding items relating to advance care planning to the statewide or organisation-wide incident management and investigation systems. For example, in South Australia, items relating to advance care planning have been added to statewide incident reporting systems, including:

  • Delay or failure in obtaining the advance care plan
  • Missing, inadequate or illegible documentation of the advance care plan
  • Communication inadequate or failed between clinicians
  • Communication inadequate or failed between substitute decision-maker/family/carers and clinicians
  • Patient incorrectly identified or advance care plan does not match patient
  • Substitute decision-maker contact delayed or not attempted
  • Dispute between clinicians
  • Dispute between substitute decision-maker/family/carers and clinicians
  • Advance care plan ignored, not followed or not used
  • Planned treatment option unavailable.