This action states

Patients are supported to document clear advance care plans

Intent

Patients are supported to document clear advance care plans.

Reflective question

What processes are in place to support patients to document an advance care plan?

Key task

Develop processes to support patients to document clear advance care plans.

Strategies for improvement

Hospitals

Advance care planning is a process of preparing for likely future healthcare scenarios. Documented advance care plans or directives come into effect when a patient no longer has the capacity to make decisions for themselves.

The laws that govern advance care plans and directives differ across Australian states and territories. Consider relevant legislation and guidelines when developing advance care planning processes for the health service organisation. The Advance Care Planning Australian website includes links to information and resources, specific to each state and territory, for different populations (including children) in different settings (for example, mental health or intensive care).

Ensure that the advance care planning process includes discussion of a patient’s values, preferences, and personal and family circumstances, and occurs in the context of their medical history and condition.

When undertaking advance care planning, patients need to consider many issues, including:

  • How their previous experiences of health care influence their preferences for future care
  • The quality of life that would be acceptable to them
  • Who they would want to speak for them if they lack the capacity to take part in decision-making
  • How they will maintain the relevance and currency of their advance care plan.

Outcomes of advance care planning may include nomination of a substitute decision-maker, or documentation of an advance care plan or directive. Patients may want to consider a number of different scenarios through advance care planning, such as their wishes and preferences for future care when:

  • An episode of acute deterioration in mental state occurs
  • Progressive cognitive decline associated with dementia occurs
  • Decisions about end-of-life care are needed.

Advance care planning is an iterative process, and multiple discussions may be needed. Documented advance care plans need to be updated over time.

Include the following in the system for supporting patients to document advance care plans:

  • Promotion of advance care planning as an important tool in providing care that aligns with patient preferences
  • Consistency with legislative, common law and state or territory requirements
  • A senior clinical lead to oversee implementation, evaluation and improvement of advance care planning processes
  • Policies and procedures that describe the roles and responsibilities of patients, carers, witnesses, substitute decision-makers and clinicians in advance care planning, and the process for documenting and updating advance care plans
  • Information resources, forms and other tools for patients and carers to consider, and document advance care plans in accordance with their wishes.

Day Procedure Services

Given the very short length of stay for most patients using day procedure services, this action will not be applicable for most services.

Action 5.17 regarding receiving and documenting advance care plans remains applicable. Further strategies and examples of evidence are available in the hospitals tab.

MPS & Small Hospitals

Advance care planning is a process of preparing for likely future healthcare scenarios. Documented advance care plans or directives come into effect when a patient no longer has the capacity to make decisions for themselves.

The laws that govern advance care plans and directives differ across Australian states and territories. Consider relevant legislation and guidelines when developing advance care planning processes for the health service organisation. The Advance Care Planning Australia website includes links to information and resources for different populations (including children) in different settings (for example, mental health or intensive care).

Ensure that the advance care planning process includes discussion of a patient’s values, preferences, and personal and family circumstances, and occurs in the context of their medical history and condition.

When undertaking advance care planning, patients need to consider many issues, including:

  • How their previous experiences of health care influence their preferences for future care
  • The quality of life that would be acceptable to them
  • Who they would want to speak for them if they lack capacity to take part in decision-making
  • How they will maintain the relevance and currency of their advance care plan.

Outcomes of advance care planning may include nomination of a substitute decision-maker, or documentation of an advance care plan or directive. Patients may want to consider a number of different scenarios through advance care planning, such as their wishes and preferences for future care when:

  • An episode of acute deterioration in mental state occurs
  • Progressive cognitive decline associated with dementia occurs
  • Decisions about end-of-life care are needed.

Advance care planning is an iterative process, and multiple discussions may be needed. Documented advance care plans need to be updated over time.

Include the following in the system for supporting patients to document advance care plans:

  • Promotion of advance care planning as an important tool in providing care that aligns with patient preferences
  • Consistency with legislative, common law and state or territory requirements
  • A senior clinical lead to oversee implementation, evaluation and improvement of advance care planning processes
  • Policies and procedures that describe the roles and responsibilities of patients, carers, witnesses, substitute decision-makers and clinicians in advance care planning, and the process for documenting and updating advance care plans
  • Information resources, forms and other tools for patients and carers to consider, and documentation of advance care plans in accordance with their wishes.

Hospitals

Advance care planning is a process of preparing for likely future healthcare scenarios. Documented advance care plans or directives come into effect when a patient no longer has the capacity to make decisions for themselves.

The laws that govern advance care plans and directives differ across Australian states and territories. Consider relevant legislation and guidelines when developing advance care planning processes for the health service organisation. The Advance Care Planning Australian website includes links to information and resources, specific to each state and territory, for different populations (including children) in different settings (for example, mental health or intensive care).

Ensure that the advance care planning process includes discussion of a patient’s values, preferences, and personal and family circumstances, and occurs in the context of their medical history and condition.

When undertaking advance care planning, patients need to consider many issues, including:

  • How their previous experiences of health care influence their preferences for future care
  • The quality of life that would be acceptable to them
  • Who they would want to speak for them if they lack the capacity to take part in decision-making
  • How they will maintain the relevance and currency of their advance care plan.

Outcomes of advance care planning may include nomination of a substitute decision-maker, or documentation of an advance care plan or directive. Patients may want to consider a number of different scenarios through advance care planning, such as their wishes and preferences for future care when:

  • An episode of acute deterioration in mental state occurs
  • Progressive cognitive decline associated with dementia occurs
  • Decisions about end-of-life care are needed.

Advance care planning is an iterative process, and multiple discussions may be needed. Documented advance care plans need to be updated over time.

Include the following in the system for supporting patients to document advance care plans:

  • Promotion of advance care planning as an important tool in providing care that aligns with patient preferences
  • Consistency with legislative, common law and state or territory requirements
  • A senior clinical lead to oversee implementation, evaluation and improvement of advance care planning processes
  • Policies and procedures that describe the roles and responsibilities of patients, carers, witnesses, substitute decision-makers and clinicians in advance care planning, and the process for documenting and updating advance care plans
  • Information resources, forms and other tools for patients and carers to consider, and document advance care plans in accordance with their wishes.

Day Procedure Services

Given the very short length of stay for most patients using day procedure services, this action will not be applicable for most services.

Action 5.17 regarding receiving and documenting advance care plans remains applicable. Further strategies and examples of evidence are available in the hospitals tab.

MPS & Small Hospitals

Advance care planning is a process of preparing for likely future healthcare scenarios. Documented advance care plans or directives come into effect when a patient no longer has the capacity to make decisions for themselves.

The laws that govern advance care plans and directives differ across Australian states and territories. Consider relevant legislation and guidelines when developing advance care planning processes for the health service organisation. The Advance Care Planning Australia website includes links to information and resources for different populations (including children) in different settings (for example, mental health or intensive care).

Ensure that the advance care planning process includes discussion of a patient’s values, preferences, and personal and family circumstances, and occurs in the context of their medical history and condition.

When undertaking advance care planning, patients need to consider many issues, including:

  • How their previous experiences of health care influence their preferences for future care
  • The quality of life that would be acceptable to them
  • Who they would want to speak for them if they lack capacity to take part in decision-making
  • How they will maintain the relevance and currency of their advance care plan.

Outcomes of advance care planning may include nomination of a substitute decision-maker, or documentation of an advance care plan or directive. Patients may want to consider a number of different scenarios through advance care planning, such as their wishes and preferences for future care when:

  • An episode of acute deterioration in mental state occurs
  • Progressive cognitive decline associated with dementia occurs
  • Decisions about end-of-life care are needed.

Advance care planning is an iterative process, and multiple discussions may be needed. Documented advance care plans need to be updated over time.

Include the following in the system for supporting patients to document advance care plans:

  • Promotion of advance care planning as an important tool in providing care that aligns with patient preferences
  • Consistency with legislative, common law and state or territory requirements
  • A senior clinical lead to oversee implementation, evaluation and improvement of advance care planning processes
  • Policies and procedures that describe the roles and responsibilities of patients, carers, witnesses, substitute decision-makers and clinicians in advance care planning, and the process for documenting and updating advance care plans
  • Information resources, forms and other tools for patients and carers to consider, and documentation of advance care plans in accordance with their wishes.