Advance care planning in the community
Timely decision-making before any health crisis reduces the burden for the family and helps to build care that's centred on the person's preferences.
It's never too early to begin a conversation about medical treatment and care preferences to prepare for a time when a person might not be able to make or communicate their values and preferences. Making important decisions about future care sooner rather than later provides individuals and families with time to discuss what is really important for them to live well. It can help the person and family regain a sense of control.
Establishing community awareness through group presentations, media, stories and stakeholder partnerships are essential to successful implementation of advance care planning into the community.
General Practitioners (GPs) in particular are integral to the commencement of advance care planning discussions in the community. The established trust and confidence of GPs means that treatment decisions can be made in a non-acute phase of a person’s illness. Advance care planning can be introduced through usual assessments and care planning such as the 75+ Health Assessment and Chronic Disease Management planning or routine consultations, including follow-up consultations after a hospital admission.
Patients may expect their GPs, with whom they have a rapport, to initiate advance care planning or end of life discussions1. The role of GPs is pivotal in supporting their patients through the planning process, involving the discussion of any problematic issues, and providing information regarding the patient’s current health status, prognosis and future treatment options.
Strong links need to be established between health services - such as primary health networks, private hospitals and other community health service providers - in order to support processes and systems so that information can be transferred and accessible, should it be required.
Barwon Health’s Advance Care Planning program has collaborated with Barwon Primary Health Network and the region’s General Practices to provide advance care planning in the general practice clinics. Trained staff from Barwon Health's program facilitate advance care planning clinics at the practices for patients referred by their GPs. This advance care planning service has seen patients exhibiting a high rate of acceptance, participation, document completion (87%) and satisfaction when advance care planning is provided through General Practice.
General practice nurses can also play a pivotal role in advance care planning. The Advance Project, led by HammondCare, provides training and resources to enable nurses to work with general practitioners to initiate palliative care and advance care planning with aged or chronically sick people as part of routine health assessments.
The Decision Assist Primary Care project developed a successful and sustainable model for advance care planning education in primary care. This was achieved by utilising a 'train the trainer' model at education and trained 'advance care planning champions' to deliver the training. The outcomes of champion-delivered training were similar to that delivered by 'advance care planning experts'.
1. Melissa Bloomer et al: End of life care. The importance of advance care planning. J Aust Fam Phys2010:39:737