What is my role?

Have the conversation

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.

  • Discuss your preferences with family, friends, doctor and other care providers
  • Appoint a substitute decision-maker. In some states/territories, this may be a Medical Enduring Power of Attorney (MEPOA)
  • Make sure this person knows your values and preferences
  • Write an advance care plan
  • Ensure that your GP, family and other care providers know who the substitute decision-maker is
  • Give a copy of your advance care plan to your GP, relevant care providers, family members and substitute decision-maker
  • Send a copy to the local hospital for their medical records
  • Keep a copy of your advance care plan for easy access for ambulance and carers (such as with your medications or on the fridge)
  • Record who the custodian of your advance care plan is on your MyHealth Record
  • Upload a copy of your advance care plan and other documentation to your MyHealth Record
  • Review your advance care plan and preferences as your health care needs or your circumstances change
  • Keeping a record of who has a copy and make sure everyone who needs it has a new or updated copy if anything changes

Find out more about advance care planning in the community >

  • 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 plan (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 plan-related documents in medical records so they are accessible when needed
  • Share information about the person's advance care plan 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 plan to inform decisions when they lose capacity

Find out more about advance care planning in various settings >

  • 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 plan 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 plan 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 plan 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 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 (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 plan-related documents in the person’s records so they are accessible when needed
  • Create alerts so all staff know that an advance care plan 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 plan 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

Find out more about advance care planning in hospitals >

  • 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 plan 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 plan exists
  • Use the person's advance care plan 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 plan
  • Involve other services (such palliative care, residential, in-reach) where required to ensure the person can access care in their preferred place
Find out more about advance care planning in various settings >
  • 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 RDNS champions, GP, palliative care for support to develop a person's advance care plan
  • Use the person's advance care plan to inform decisions about care if the person loses capacity
Find out more about advance care planning in various settings >
  • 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 plan
  • Encourage the person to share their advance care plan with others involved in their care
Find out more about advance care planning in the community > 

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

Find out more about advance care planning in various settings >

This information was produced by the North Western Melbourne Primary Health Network.

Dad in wheelchair with kids at playground

Advance care planning for health and care workers

Advance care planning in various settings and groups

Different settings may need different approaches to start the conversation.

Find out more

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