Roles and responsibilities in advance care planning

Who should be involved in advance care planning?

The healthcare system is complex. Everyone needs to work together to put patients at the centre.

Advance care planning is about relationships between individuals, their families and carers, health professionals, community organisations and healthcare organisations. Each group has its own roles and responsibilities to ensure that Australians' healthcare preferences are respected.

Organisations can also support the process by having good policies and guidelines and by making current information available.

The following information was sourced from the Roles and Responsibilities in Advance Care Planning resource produced by the North Western Melbourne Primary Health Network.

  • Identify existing documents/substitute decision-maker(s) for all patients as part of usual processes; record any details
  • Provide patients with information about advance care planning
  • Discuss health issues, condition, treatment options, prognosis and advance care planning
  • Encourage discussion with substitute decision-maker and involve the substitute decision-maker and the person's family where possible and appropriate
  • Assist the person to document their Advance Care Directive (if required); check any draft documents and help to clarify wording or intentions
  • Record discussions about advance care planning in medical software and ensure others can access this information if needed
  • Store copies of Advance Care Directive-related documents in medical records so they are accessible when needed
  • Share information about the person's Advance Care Directive with others involved in care (with the person's consent) such as hospitals and specialists
  • Encourage the person to give copies to anyone who may be involved in making decisions about their care
  • Ensure that  information is available if care is needed "after hours" (medical deputising or locum services, for example)
  • Review regularly/as needed
  • Activate when needed – use the person's Advance Care Directive to inform decisions when they lose capacity

  • Identify existing documents/substitute decision-maker(s) for all residents as part of admission processes; record any details
  • Provide residents and families with user-friendly information about advance care planning
  • Discuss advance care planning and how it relates to resident’s health issues, condition and treatment options
  • Involve the resident’s GP in discussions where possible and appropriate
  • Encourage discussion with the person's substitute decision-maker and involve the substitute decision-maker/family where possible and appropriate
  • Support the resident/family to document their advance care plan, check any draft documents and help to clarify wording or intentions
  • Record any discussions about advance care planning and ensure others can access this information if needed
  • Store copies of advance care planning-related documents in the resident’s records so they are accessible when needed
  • Share information about the resident’s Advance Care Directive with others involved in care with the person's consent (such as with the person's substitute decision-maker, hospital, specialists, in-reach, Locum, ambulance services
  • Ensure that information is available if care is needed "after hours" (medical deputising or locum services, for example)
  • Review regularly (such as part of Resident of the Day, annual comprehensive medical assessments, or when conditions change or resident deteriorates)
  • Use the person's Advance Care Directive to inform care decisions, including when resident’s condition deteriorates
  • Engage with community palliative care and residential in-reach/out-reach services to ensure residents have access to the care they need in their preferred place

  • Identify existing documents/substitute decision-maker(s) for patients as part of admission processes; record any details
  • Receive copies of the Advance Care Directive from patients or other health services (such as residential aged care facilities or GPs); provide clear instructions on how to do this
  • Provide patients and families with user-friendly information about advance care planning
  • Discuss advance care planning and how this relates to patient’s health issues, condition, prognosis and treatment options
  • Encourage discussion with the person's substitute decision-maker and involve the substitute decision-maker/family where possible and appropriate
  • Support the person and family to document their Advance Care Directive; check any draft documents and help to clarify wording or intentions
  • Record any discussions about advance care planning and ensure others can access this information if needed (such as on discussion cards or e-systems)
  • If advance care planning conversations or limitations of treatment that have ongoing currency have occurred, inform the person's GP and encourage advance care planning documentation (if not already done)
  • Store copies of Advance Care Directive-related documents in the person’s records so they are accessible when needed
  • Create alerts so all staff know that an Advance Care Directive exists for the person
  • Share information and advance care planning discussions with others involved in care with the person's consent (residential aged care facilities or the person's usual GP, for example)
  • Review regularly (such as part of Resident of the Day, annual comprehensive medical assessments, or when conditions change or resident deteriorates)
  • Use the person's Advance Care Directive to inform care decisions if they lose capacity
  • Provide clear point of contact for community-based health professionals to seek advice on advance care planning.

  • Identify existing documents/substitute decision-maker(s) for patients
  • Receive advance care planning information from the person's residential aged care facilities and their usual GP
  • Where an Advance Care Directive exists, discuss how this relates to patient’s health issues, condition, prognosis and treatment options
  • Encourage discussion with the person's substitute decision-maker and involve the substitute decision-maker/family where possible and appropriate
  • Involve the substitute decision-maker and family in decision-making
  • Record any discussions about advance care planning and ensure others can access this information if needed (such as on e-systems)
  • Create alerts in medical records, so all staff know that an Advance Care Directive exists
  • Use the person's Advance Care Directive to inform care decisions if patient loses capacity in the context of the current visit
  • Communicate with person's usual GP/care provider regarding their Advance Care Directive
  • Involve other services (such palliative care, residential, in-reach) where required to ensure the person can access care in their preferred place.
  • Provide information and explain advance care planning to patients/clients
  • Encourage discussions with family and substitute decision-maker about advance care planning
  • Identify existing documents/substitute decision-maker(s)
  • Record details of advance care planning conversations in records. Share the details with others (with the person's consent) and transfer across settings
  • Refer to Advance Care Planning nurse consultants or champions, GP, palliative care services for support to develop a person’s Advance Care Directive.
  • Use the person's Advance Care Directive to inform decisions about care if the person loses capacity.
  • Provide user-friendly information to clients and explain advance care planning
  • Provide information about where a person can go for further support if needed
  • Encourage discussions with the person's family and substitute decision-maker
  • Identify existing documents/substitute decision-maker(s)
  • Record details of advance care planning conversations in records
  • Refer to organisational champions, GP, and palliative care for support to develop a person's Advance Care Directive
  • Encourage the person to share their Advance Care Directive with others involved in their care

Support local primary and community providers by:

  • Ensuring access to education and training for advance care planning (both 'basic' and 'champion' level training)
  • Providing access to resources and tools to implement advance care planning as a part of usual practice
  • Facilitating engagement with hospital advance care planning programs and across various health care settings
  • Supporting improvements in systems for integration and transfer of advance care planning information (eHealth, for example)
  • Advocating to the State and Commonwealth Departments of Health regarding any advance care planning-related issues that are impacting on primary health care providers and their patients/clients in the primary health network region

Support local community members by:

  • Increasing the knowledge and skills of health and community care providers to support their patients and clients
  • Ensuring appropriate advance care planning information is available to the community, by working with other health care organisations, service providers, consumer groups, community organisations and local councils
  • Advocating to the State and Commonwealth Government Departments regarding  issues identified for our community relating to advance care planning


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