Are you ready to support clients to plan ahead for their end of life care?

Advance Care Planning

Advanced Care Directives (ACD) when considered in the broader context of advanced care planning allow people to plan ahead and document their preferences regarding their end of life care, to live well and to die well with dignity in accordance with their values and preferences.

Advance care planning has benefits for the person, family members, and carers. However, the uptake of advance care planning in the community, when people still have the capacity to make decisions is low. Many people entering aged care facilities may have already lost their decision making capacity.

An ACD may record a person’s values and preference related to treatment outcomes, or details about refusal of treatment and may appoint a substitute decision maker (SDM).

Decision makers

Where a person has decision making capacity any issues identified or directions which may be vague with the ACD can be clarified with them directly.

• If the person no longer has decision making capacity, then what?
  Where an SDM has been appointed, they are responsible for making the decision that they believe the person would have made in that situation.
  The SDM should base their decision on their knowledge of the person’s life goals, preferences and values in the context of the specific situation.
• If there is no ACD and no SDM, then what?
  The legislation varies between states and territories regarding medical decision makers where a SDM or a medical agent or medical attorney has not formally been appointed.

Incorporating Advance Care Planning in to your governance systems

It is important that Providers have robust systems and governance to support staff to implement advanced care planning in a person centred care context.

With this week being National Palliative Care Week, it is a timely opportunity to conduct a health check on how advance care planning has been implemented into your organisation.

• Do you have an organisation-wide evidence based Advanced Care Planning Policy and Procedures, Is it current? When was it last reviewed? Does it need to be updated?
• Are advanced care planning discussions embedded as part of your admission and assessment process?
• Are your staff empowered and competent to initiate Advanced Care Planning discussions?
• Can your staff identify who are the appropriate decision makers?
• How effectively have you embedding advanced care planning into routine care?
• Do you provide education for staff on how ACDs relate to goals of care, powers of attorney, refusal of treatment or not for resuscitation forms?
• Do you have effective systems to create alerts, store, record and retrieve ACDs?
• How effective are your systems and avenues for sharing ACDs with other facilities, hospitals, GPs.

Gadens can assist providers with implementing and monitoring advance care planning within your services’ everyday practices.