General practice considerations

Why advance care planning is important in general practice settings

Australia has an ageing population and growing prevalence of chronic and complex health conditions, often managed in primary care. General practitioners (GPs) and general practice nurses often develop long and trusting relationships with patients. This makes the general practice setting the ideal place to promote and facilitate advance care planning. It’s best to discuss planning for the future when a person’s health is stable. General practices should aim to include advance care planning as part of routine health care involving all team members.

Your role in general practice

Supporting processes to promote uptake in general practice settings may involve introducing screening to identify suitable patients. You can take the opportunity to start conversations by recognising cues. This helps make advance care planning a normal part of standard consults and age-based health checks.

Common triggers and cues to start a conversation about advance care planning in general practice settings include:

• when a person asks about planning for their future
• routine health checks and activities such as 75+ years health assessment and GP chronic condition management plan consultations
• when an older person receives their annual flu vaccination
• on admission to residential or community care services
• diagnosis of a life-limiting illness or a chronic condition
• beginning palliative or end of life care.

Many patients do want to talk to their clinicians about advance care planning. In fact, they often expect health care providers to initiate these conversations. They view it as a way to prepare their loved ones and decrease their decisional burden. Approaching advance care planning conversations from the perspective of values and preferences is a sensitive way to plan for the future. Conversations may start with, ‘If you did become more unwell, what would be most important to you?’ Done well, advance care planning conversations can support the therapeutic relationship and build trust.

The Advance Project team developed a conversation guide for use with healthy people to open a discussion about advance care planning by GPs. Access the paper including the structured conversation guide in the Australian Journal of General Practice.

‘Busy workloads and time constraints, inadequate training and lack of remuneration just make it all too hard…’

Workplace culture is very important to successfully incorporating advance care planning in general practices. Commitment from the whole practice is an enabler. There shouldn’t be a reliance on one staff member to initiate these conversations. Doctors, nurses, practice managers and administrative staff all require a shared understanding of advance care planning. This includes its importance and value, their roles, documentation and funding strategies.

Advance care planning may include discussions, documentation in notes and/or an advance care directive, and uploading documents to My Health Record. This may be completed over a number of short time-tiered general attendance consults or during one or more long consults. Longer consults (Level D and E) may be needed if the patient needs more time and support to communicate. This includes patients with dementia, disability, or those who need an interpreter.

Read more about the role all health and aged care staff have in advance care planning.

Supporting advance care planning in general practice: Guidance on Medicare Benefits Schedule item use

The Supporting advance care planning in general practice factsheet provides practical guidance for general practitioners, practice nurses and primary care teams on how to integrate advance care planning into routine processes and clinical care, supported by using relevant MBS items.

The factsheet outlines opportunities to initiate advance care planning during:

• health assessments
• chronic disease management planning
• time‑tiered consultations

It also explains how advance care planning activities, such as exploring values, documenting preferences, and uploading advance care planning documents to My Health Record, align with specific Medicare consultation items.

The resource supports clinicians to follow the advance care planning process using the Think–Talk–Record–Share–Review process. It includes clear examples, recommended tools and links to national and state-based forms and resources. The aim is to build confidence in initiating conversations, guiding patient decision-making, and ensuring advance care planning documentation is communicated and accessible across care settings.

Download the Supporting advance care planning in general practice factsheet

Supporting service delivery

ACPA Learning

To learn more about advance care planning, try our microlearning campaigns.

The Advance Project

The Advance Project supports Australian health professionals with advance care planning. Their website, resources and training packages can help GPs, nurses and general practice managers embed advance care planning in general practice.

Learn more about The Advance Project general practice training and resources on their website.

RACGP

RACGP has information about advance care planning including practice tools and a position statement on their website.