Key messages

  • Advance care planning can be initiated at a number of points during treatment.
  • Advance care planning doesn’t need to be completed all in one go. It is better to start the conversation and then follow up at future routine consultations.
  • Taking time to prepare for an advance care planning conversation will result in everyone having a positive experience.
  • The advance care planning cycle gives a complete overview of the planning process.

When to start an advance care planning conversation

Advance care planning can be initiated at a number of points during a person’s treatment including:

  • when a person indicates they would like to discuss their future care and treatment
  • by clinicians at key points in the person’s illness trajectory (such as after hospitalisation)
  • when there is a change in the condition or the person experiences an unstable phase of illness
  • as a routine part of the care for key groups, such as those with chronic progressive disease, early cognitive decline, people approaching end of life, and people who are managing multiple comorbidities
  • by a person who is isolated or vulnerable.

Once initiated, there are three steps a person can take to plan ahead:

  • Appoint someone to be their medical treatment decision maker
  • Talk to their friends, family and loved ones about what matters most to them
  • Document their values and preferences for medical treatment in an advance care directive
Advance care planning does not need to be completed all in one go. It is preferable to start the conversation and develop a written advance care directive during future routine consultations.

What the conversation should include

An advance care planning conversation should include the following:

  • identifying the health decisions that are important to the person
  • identifying who would make decisions if the person was unable to participate
  • determining and documenting what those decisions would be.

A positive experience for everyone involved will result from taking time to prepare for the discussion and holding it in a suitable environment.

Although the law does not prescribe that a person must use a standardised advance care directive to document their wishes for future care, there are a number of formal requirements that must be met in order for an advance care directive to be valid.

If your health service has not developed its own advance care directive, there is a template form developed by the Department of Health and Human Services available on the advance care planning forms page.

The advance care planning cycle

The advance care planning cycle has three phases: develop, review and activate.

Develop

Talk to the person about their values and preferences for medical treatment, and assist them to document their decisions in an advance care directive.

Actions

  • Initiate the conversation.
  • Reflect and discuss.
  • Record and document.

Review

An advance care directive can be reviewed at any time. Reviewing is important, because people refine their goals for treatment and care during the course of their illness. An up-to-date advance care directive also makes it easier for clinicians to assess its validity.

Actions

  • Discuss reviewing the existing advance care directive.
  • Reflect and discuss.
  • Record and document any changes.

Activate

An advance care directive is activated when a person cannot be directly involved in decision-making because of a lack of capacity or inability to communicate.

All clinicians involved in the person’s care are responsible for activating the advance care directive in consultation with the person's medical treatment decision maker and family members.

Actions

  • Consider what treatment is required for the person.
  • Gauge whether the person is competent to make a decision.
    • If the person is competent, discuss treatment with the person. They will then make a decision regarding the medical treatment. 
    • If the person is not competent, check for an advance care directive and any relevant instructions regarding specific medical treatment.
    • If there are no instructions in the advance care directive, or if no advance care directive is available, discuss treatment with the medical treatment decision maker and family members.
  • The medical treatment decision maker will then make the medical decision, informed by information documented within any advance care directive.

For more information refer to Advance care planning - have the conversation: a strategy for Victorian health services 2014-­18 (Part 2: Having the advance care planning conversation).

Videos on initiating advance care planning for health professionals

The Department of Health & Human Services has developed a series of videos for health professionals to guide them on effective communication with patients about advance care planning, in particular informed consent, treatment plans and care options. 

Introduction to initiating the advance care planning conversation

Putting pen to paper

Putting pen to paper - commentary

Acute hospital vignettes

Acute hospital vignettes - commentary

Documentation guide

A successful conversation (female consumer)

A successful conversation (female consumer) - commentary

A successful conversation (male consumer)

A successful conversation (male consumer) - commentary

An unsuccessful conversation (female consumer)

An unsuccessful conversation (female consumer) - commentary

An unsuccessful conversation (male consumer)

An unsuccessful conversation (male consumer) - commentary

Other videos about advance care planning

Making a decision - Advance Care Planning Australia

Making a difference - Advance Care Planning Australia 

The five steps of advance care planning - John Hunter Hospital

End of life planning - Hungry Beast

Care planning - Advance Care Planning Australia

Dot’s story – Advance Care Planning Australia

George’s story – Advance Care Planning Australia

James’ story – Advance Care Planning Australia

Speak Up! - Advance Care Planning Australia

ACP Conversations - Canadian Hospice Palliative Care Association

I didn’t want that – Dying Matters

How to talk end-of-life care with a dying patient - New Yorker Festival

I’ll Think About It Tomorrow – Health Issues Centre

Taking Care Of Dying Time – Central Hume Primary Care Partnership