Information 1-3

  • A voluntary process of planning for future health and personal care where a person’s values, beliefs and preferences are documented to guide decision-making at a time when a person cannot make or communicate decisions
  • Consider Advance Care Planning (ACP) for all adult persons, particularly those who are older, frail, have a chronic condition, multiple diseases, early cognitive impairment or who are approaching their end of life. ACP can:
    • improve satisfaction with care
    • reduce stress, anxiety and depression
    • reduce unwanted or non-beneficial invasive treatment at end-of-life
    • support early initiation of palliative care
    • increase likelihood of dying in preferred place of death
    • guide appropriate transfers to hospital
  • Resuscitation planning should occur as part of the ACP process so that patients have their views and wishes respected at end-of-life
  • Revisit ACP over time and when health or life circumstances change

Health check recommendations

  • All adults from 18 years of age

1. Procedure

  • The clinician asks themselves the “surprise question”:
    • “Given all I know about this person’s health and behaviours, would I be surprised if they were to pass away in the next 6–12 months?”
  • Assess people who may benefit from ACP. See Table 1. and Resource 1.
  • If the answer is ‘no, I would not be surprised’, then undertake ACP
  • Ensure the person feels safe to talk, providing sufficient time, privacy and reassurance. See Engaging our patients
  • Be respectful and recognise local cultural practices and expectations. If unsure engage the palliative support services. See Resources 2–3.
  • Where appropriate, with the person’s permission, include significant others and substitute decision-makers in discussions
  • Review the person’s notes to prepare necessary information and answers to questions that may arise:
  • Check for existing ACP documents in the medical records or the ACP Tracker. See Resource 4.
  • Not all ACP conversations will be completed in one visit
  • See Resources 5. for more information

Table 1. Prompts and considerations for those who may benefit from ACP

Recent or repeated unplanned hospitalisations for a chronic or severe progressive illness

  • Declining function or reduced response to treatments indicates approaching end of life

A resident of an aged care, retirement village or a person with a life-limiting condition

  • ACP is appropriate for this group of persons

The person appears not to have decision making capacity for the conversation

  • Aim to include significant others in discussions if possible

Significant others enquiring about palliative care or ACP

  • This flags a need for assessment

Requests for ACP

  • Recognise non-verbal cues. Acknowledge painful emotions

Statements about stopping treatment or wishing to pass away

  • Explore reasons i.e. persistent pain, fear, need for spiritual support, mental health

Current ACP documents requiring review

  • Review or prepare new documents when the person is well enough to think and communicate clearly
  1. Getting started 1,4,5,6
  • Invite the person to talk about their health concerns. Prompts may include:
    • what have you noticed since your recent diagnosis? Your last trip to hospital? Starting new treatment?
    • how worried are you about the future? Have you talked about your concerns with significant others?
    • what is most important to you now? What makes your days enjoyable?
    • have you had past experiences of health care that influences how you would like to be cared for in the future?
    • how important is your independence? e.g. toileting, feeding, talking with family, socialising with others? Offer examples appropriate to the person
  • Invite the person to write down their wishes or directions by completing the ACP document(s) they consider meet their needs:
    • Advance Health Directive (AHD)
    • Enduring Power of Attorney (EPoA)
    • Statement of Choices (SoC)
  • Consider making a Queensland Health Acute Resuscitation Plan (ARP). See Resource 6.

2. Results

  • Completed original documents remain with the person
  • File copies of documents in the person’s chart
  • Send a copy to the Statewide Office of ACP (if not on the ACP Tracker). See Resource 7.
  1. Advance Health Directive (AHD) for ACP purposes

Purpose

  • Used in certain circumstances to provide directions about future health care and special health care
  • It can also be used to appoint an attorney for health matters

Type

  • Legally binding

Completion

  • Completed freely and voluntarily by a person who is > 18 years of age and who has capacity to understand the document they are signing and the powers it gives See Resource 8.

Authorisation

  • A doctor or Nurse Practitioner must complete Section 5, and the document must be witnessed by an eligible witness (Justice of the Peace, a Commissioner for Declarations, a lawyer or a notary public)

Activates

  • When a person does not have capacity to make their own healthcare decisions. See Resource 8.

Changes

  • The AHD should be reviewed regularly and when the person’s condition or preferences change
  • Can be revoked by the person while they have decision-making capacity

See Resource 9. for ACP forms in Queensland

  1. Enduring Power of Attorney (EPoA) for ACP purposes

Purpose

  • Allows a person to legally appoint attorney(s) for personal, health or financial matters

Type

  • Legally binding

Completion

  • Completed freely and voluntarily by a person who is > 18 years of age and who has capacity to understand the document they are signing and the powers it gives. See Resource 8.

Authorisation

  • Must be witnessed by a Justice of the Peace, a Commissioner of Declarations, a lawyer or a notary public

Activates

  • For personal/health matters:
    • when the person does not have capacity to make their own decisions
  • For financial matters:
    • as specified by the person in the document, including when they do not have capacity to make decisions immediately, at a particular time, or in particular circumstances or occasions

Changes

  • Can be revoked by the person while they have decision-making capacity

See Resource 9. for ACP forms in Queensland

  1. Statement of Choices (SoC) for ACP purposes

Purpose

  • A values-based form that records a person’s views, wishes, and preferences for future health care
  • Used to guide or inform those who need to make health care decisions for a person who is unable to make those decisions themselves

Type

  • Not legally binding and does not provide consent to health care in advance

Completion

  • Form A: used by people who can make health care decisions for themselves
  • Form B: used for people who cannot make health care decisions for themselves.
  • Form B is completed by the person’s legally appointed substitute decision-maker(s), or, if not applicable, person(s) in a close and continuing relationship with the individual. A person’s healthcare providers should not complete the SoC on a person’s behalf

Authorisation

  • Signed by person completing the form, and their doctor or Nurse Practitioner

Activates

  • When the person does not have capacity to make their own healthcare decisions. See Resource 8.

Changes

  • It can be reviewed and updated as required to ensure it reflects a person’s current wishes

See Resource 9. for ACP forms in Queensland

  1. Queensland Health Acute Resuscitation Plan (ARP) for ACP purposes

Purpose

  • A medical order that provides documentation of:
    • discussions regarding cardiopulmonary resuscitation (CPR) and ventilation
    • clinical authority to act on the order in an acute emergency
    • available and recommended treatments

Type

  • Not a legal document and does not substitute for legal consent

Completion

  • Completed by a medical practitioner/health professional for adults:
    • at risk of cardiac and/or respiratory arrest in the foreseeable future or
    • where death can be reasonably expected within 12 months

Authorisation

  • Signed by a medical practitioner/health professional
  • Can be used by Queensland Health and Non-Queensland Health organisations. Usage is subject to that service’s policies and procedures

Active for

  • All clinicians exercise their clinical judgement when acting on an ARP:
    • at this admission/attendance or
    • until a specified date within 12 months or
    • for 12 months

Changes

  • An MO must review a patient’s ARP form:
    • when a patient presents to a Queensland Health service or
    • following attendance by Queensland Ambulance Service or if the patient:
      • regains capacity for decision-making or
      • changes their preferences for resuscitation or
      • has changes to personal circumstances (e.g. different substitute decision-maker), health status or nature of intended health care or outcome

See Resource 6. for ARP forms and resources in Queensland

3. Brief intervention

  • If the person doesn’t wish to discuss ACP wait until next visit
  • For people with impaired decision-making capacity, enact their statutory ACP documents or use non-statutory ACP documents to guide discussions with substitute decision makers
  • Integrate person-centred choices into medical treatment plans and involve other services to enable the person to access care in accordance with their preferences
  • Encourage the person to provide copies of their documents to significant others and substitute decision makers
  • For further information see Resource 4.

4. Referral

  • With consent involve other health professionals in further discussions to continue the support process
  • Refer to your local state Advance Care Planning support services who will:
    • provide information and resources about advance care planning
    • connect people to local advance care planning services
    • share documented health care wishes with clinicians and across services involved in a person’s care e.g. GP’s
  • In Queensland the Office of Advance Care Planning is available for contact on 1300 007 227 or via email at: acp@health.qld.gov.au Monday to Friday 0800–1600

5. Follow-up

  • Send a copy of Advanced Health Directives, Enduring Power of Attorneys, revocation documents, Queensland Civil and Administrative Tribunal Decisions and Statement of Choices to the Office of ACP to review and upload to the patient’s Queensland Health hospital record (The Viewer) via:
    • Email: acp@health.qld.gov.au
    • Fax: 1300 008 22
    • Post: PO Box 2274, Runcorn, Qld 4113
ACP documents uploaded to the ACP tracker (in the Viewer) can be accessed by authorised clinicians across Queensland Health public hospitals, Queensland Ambulance Service, Mater Health; as well as general practitioners, medical specialists, nurses, midwives and pharmacists (external to Queensland Health) who have registered for access to the Health Provider Portal Look for the pink ACP logo in the menu bar
ACP logo/badge that appears in the user interface of the Viewer
  • To create an account in the Health Provider Portal. See Resource 10.
  • The person can upload their ACP documents to their My Health Record if they wish

6. References

7. Resources

  1. A multidisciplinary guide to identify those who may benefit from advance care planning
  2. Aboriginal and Torres Straight Islander resources for clinicians approaching topics of death, dying and difficult conversations in a culturally sensitive way
  3. Advance Care Planning Australia and My Care, My Choices: Advance Care Planning
  4. ACP Tracker: The advance care planning information sharing portal
  5. Palliative and end-of-life care framework – last 12 months of life
  6. ARP forms, guidelines and tools in Queensland and ARPs via The Viewer/ieMR
  7. Statewide Office of Advance Care Planning Checklist for ACP documents to be uploaded
  8. The Queensland Capacity Assessment Guidelines 2020 to help understand capacity
  9. Online writeable PDF ACP documents can be downloaded from My care, My Choices, printed ACP forms available upon request from the Office of ACP
  10. The Health Provider Portal

Last updated: November 2024

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