The following best practice standards can guide a clinician’s approach to developing or activating an advance care plan.
Decisions are person-centred
Care decisions reflect personal views and choices and those preferences should be honoured at all times.
People's autonomy is respected
Competent adults are entitled to make their own decisions about personal matters, including health. Autonomy can be exercised in different ways according the person’s culture, background, history and spiritual and religious beliefs.
If a person does not have capacity to make a decision about treatment, any valid instructional directive will apply as though the person has consented to or refused the treatment.
Adults are presumed competent
Adults should be presumed to be competent at the time of completing an advance care directive or at the time that medical treatment is offered, unless there is reason to believe this is not the case.
Health decisions may be broad
Decisions outlined in an advance care directive may be broader than just medical treatment and might include preferences in relation to quality of life, concerns for the future and unacceptable circumstances.
Decisions can relate to any time in the future
Advance care directives can relate to any future period of medical care, not just end-of-life care, where a person is unable to participate in decision-making.
Quality of life is defined by the individual
The person defines what level of functional ability defines quality of life and communicates it to their medical treatment decision maker through advance care planning.
Medical treatment decision maker
The medical treatment decision maker’s role is to ‘stand in the shoes’ of the person who lacks decision-making capacity, and to discuss medical treatment options as the person’s representative.
The medical treatment decision maker represents the person to the medical practitioner. Their role is one of advocating for the person when planning medical treatment, based on: what the person has documented in an advance care directive, what they know about the person, what is important to the person and what the person might have said or written about this decision or about medical care more generally.
The aim is for a shared understanding between the medical treatment decision maker and the medical practitioner about the person’s best interests and the medical decisions that are consistent with this.