Advance Care Planning - Department Of Health
Government of Western AustraliaDepartment of HealthWA Cancer and Palliative Care NetworkAdvance CarePlanningA step-by-step guide for health careprofessionals assisting patients withchronic conditions to plan for caretowards end of life
Advance Care PlanningContentsAdvance Care Planning ProcessIntroduction 3Identifying patients for ACP discussions: triggers and prompts4Identifying patients for ACP discussions: generic clinical indicators5Initiating the ACP discussion6During the discussion7Identifying patient’s goals and wishes7Issues to consider8Closing the discussion8Documenting ACP discussion 9Reviewing Advance Care PlanningReviewing ACP discussions10Clinical indicatorsIdentifying patients for ACP discussions: disease specific clinical indicators11Renal disease 11Chronic lung condition1213Heart failure14CancerGeneral neurological disease1516Neurological diseaseAppendixAppendix 1: Mental Capacity Assessment 17Appendix 2: The Australia – modified Karnofsky Performance Status (AKPS)18Glossary2Glossary19References21
Advance Care Planning ProcessIntroductionAdvance Care Planning (ACP) is an ongoing discussion between a patient, theircarers/family and you, about their values, beliefs, treatment and care options.In particular, their wishes for future care should they no longer be able tocommunicate their decisions at the time they are needed.ACP may assist in the development of an Advance Health Directive (AHD) andthe appointment of an Enduring Power of Guardianship (EPG) or EnduringPower of Attorney (EPA). These are legal documents and the full requirements ofthese cannot be covered in this resource. A brief summary of each of these legaldocuments can be located in the glossary, pages 19-20. For more information, dvance Care Planning ProcessThis resource focuses on the ACPconversation(s) and process. It willassist you in ACP discussions withyour patients and help you identifythose who may benefit from ACPdiscussions earlier in their illness.Cecar e PlPatientninganEPGA dva nEPAAHDThe patient must have capacity toparticipate in these discussions.This Guide includes a MentalCapacity Assessment, which willhelp you to determine the patient’scapacity to participate in the ACPprocess. Please refer to Appendix 1for more information.Many patients expect their healthcare team to initiate discussions;however, not all patients will wishto engage in ACP discussions.3
Advance Care PlanningIdentifying patients for ACP discussions: triggersand promptsWhether or not you are aware of the ACP process, patients may expect their healthcare team to initiate such discussions. It is therefore essential that health careprofessionals be sensitive to circumstances when it may be an appropriate timeto offer ACP, and to identify when patients might be indicating their readiness todiscuss. This section includes a list of triggers and clinical indicators to assist you inidentifying those patients who may benefit from ACP discussions. It is designed toencourage ACP earlier in a patient’s illness, when such discussions are likely to bemore beneficial to the patient and their carer/family.Patient and/or carerhas questions andstatements (regardlessof prognosis) that mayindicate a readiness forACP discussions /The ‘surprise’ questionExamples of comments which maysuggest interest in ACP“How will I know when the time comesto stop this treatment/medication?”“Just keep me comfortable.”“What is going to happen to me in thefuture?”“Is there any hope of recovery?”“If I’m always going to feel like this,I don’t want to go on.”“Do you think palliative care might help mymother/father?”Would you (the health careprofessional) be surprised ifthis person died within thenext 12 months?Answer‘No’ /Prognostic/clinicalindicators4Generic or disease specific clinicalindicators suggest patient may be in lastyear of life or continuing declineConsider offeringan ACP discussionwith patient/family/carers.
Advance Care Planning ProcessIdentifying patients for ACP discussions:generic clinical indicatorsThese clinical indicators are designed to assist you to identify patients who maybe ready for or who could benefit from the ACP processThey are not designed to provide patients with a prognosis or estimatehow long they have to live.GenericClinical IndicatorsTwo or more admissions to hospital for a chronic or life-limiting illness within12 months1Resident in a nursing home2Unintentional weight loss greater than 10% over 6 monthsKarnofsky Performance Status (KPS) to 50%3Deliberate non compliance with treatmentRefusing food or fluidsFrailty (patients who present with multiple co-morbidities with significantimpairment in day to day living and deteriorating functional status).45
Advance Care PlanningInitiating the discussionThis section provides an overview of the processes for facilitating ACP discussionsand includes details for documenting and communicating ACP discussions withother health care providers.Prior to holding the discussions:Do you have a private area with no interruptions?Who should be present?Does the patient and/or carer/family have the decision-making capacityto participate in the discussion?Ensure all relevant clinical information is available (review files/notes)and consult with other health care professionals involved with the patient’songoing care.5Remember, there is no recommended time frame for ACPdiscussions. These may be ongoing and can take place overseveral sessions or visitsACP and communication skillsCommunication skills are central to holding effective ACP discussions.For further information on communication skills in ACP and end-of-lifediscussions, refer to the Medical Journal of Australia supplement “Clinicalpractice guidelines for communicating prognosis and end-of-life issues withadults in the advanced stages of a life-limiting illness, and their caregivers”.5Examples of phrases to use (to initiate discussion)“Have you thought about the place where, or the type of care you would like tohave, if you ever became too ill to care for yourself?”“Do you worry about what’s going to happen to you when your heart/lungs/cancergets worse?”“Would it help you to discuss this?”“Is there someone you would prefer to make decisions about your treatment ifyou were unable to make them for yourself?”“Some people have thought about what they want and document their wishesin what is called an Advance [Health] Directive or Living Will. Do you have anAdvance [Health] Directive? Would you like to learn more about this?”6
Advance Care Planning ProcessDuring the discussion:If the patient is not interested in advance care planning discussions, ensurethey are aware that they can revisit the topic at any time in the future. Offer toprovide written information for the patient to take away if they are receptive.IntroductionExplain what ACP is and outline some of the reasons patients/carers/families etcmay want to have the discussions.Check if the patient already has an Advance Health Directive/Living Will/EnduringPower of Guardianship, Enduring Power of Attorney or similar. If so, do they needto be reviewed?Discuss the role of a proxy/substitute person or Enduring Guardian for decisionmaking.Identifying patient’s goals and wishesIdentify issues that are important to the patient at that time:– “Think about what is most important to you in your life. What makes lifemeaningful or good for you now?”6– “At this point, given your medical condition, how could we (the healthprofessionals) help you live well?”7– “Are there any special events/activities that you are looking forward to?”(e.g. birthdays, weddings, holidays etc.).What are the patient’s values/goals for care?– What is their understanding of their condition now and its prognosis?– “If you have to choose between living longer and quality of life, how would youapproach this balance?”7– “What, if any, religious or personal beliefs do you have about sickness, healthcare decision-making, or dying?“67
Advance Care PlanningIssues to considerSee disease specific issues to consider (pages 11 – 16)Identify the goals, benefits and burdens of other treatments and/or interventionsthe patient/carer/family may wish to discusse.g. CPR, ventilation, dialysis, artificial nutrition and hydration, antibiotics(e.g. “Are there any particular scenarios or interventions you would liketo avoid?”)Does the patient wish to complete an AHD?Consider discussing referral to palliative care services (if appropriate) andpreferred place for future care e.g. home, hospital, hospice etc.Is this an appropriate time to discuss organ and tissue donation?Are there other issues the patient, carer/family (if present) wants to discuss?Closing the discussionReview/summarise discussion with the patient and others present.Clarify any inconsistencies or misunderstandings.Offer additional information if required (patient resources, information sheets,referrals etc).Document all details of the ACP process.Arrange further meetings if relevant and/or offer your contact details for futurereference.8
Advance Care Planning ProcessDocumenting Advance Care Planning discussionsHealth Care ProfessionalPlace written documentation in patient’s filein a consistent and accessible sectionDetails of all individuals present duringdiscussions as well as others consultedin relation to this.Record details of topics discussed, includingfeedback from patients regarding what theyconsider acceptable treatment, along withspecifics of any treatment decisions e.g.circumstances for cessation of treatments.Documenting presence of an AHD/EPG/EPA.Document any Not for Resuscitation (NFR)orders according to your organisation’s policy.Patient InformationProvide a copy of theACP document to thepatient and their family/carer.Obtain consent to forwardcopies of the ACPdiscussion to the patient’sGeneral Practitionerand other providersas consented to byindividual/carer.Include a note/flag in the patient’s medical fileto alert to ACP documentation.If/when the patient is transferred to another care setting(s),ensure copies of the ACP discussion are included in handoverdocuments.9
Advance Care PlanningReviewing Advance Care Planning discussionsThere will be certain times in the patient’s care when ACP discussions will needto be revisited and their Advance Care Planning, including their Advance HealthDirective and Enduring Power of Guardianship reviewed.When should an Advance CarePlanning discussion, AdvanceHealth Directive and/or EnduringPower of Guardianship bereviewed?When the patient and/or carer/family requests or changestheir mind about any previousdecisions.Where the patient’s medicalcondition or individualcircumstances change(e.g. diagnosis of new illness,death of a carer/partner, changein location of care etc).When returning to hospital for anytreatment.If treatment options or medicalcare available for the patientchanges their needs in regardsto ACP (for example, a newtreatment for their disease,diagnosis of a co-morbidity etc).Patients can change or revoketheir AHD or EPG at any time.Rather than make changes to anAHD / EPG, it is recommendedthat patients preparea new one.10Reviewing “Not for CPR”(or similar) orders /-Refer to your organisation’spolicy on documenting“Not for CPR” (or similar)orders.DocumentationStaffDocumenting all ACPdiscussion reviews and/orchanges to AHD.All reviews and subsequentdiscussions should bedocumented and sharedwith relevant people(where consented to).PatientEnsuring documents aredistributed to all relevantpeople (in particular, thosewho received a copy ofprevious ACP documents).Discarding all previousACP documents fromcirculation to ensurethe most recent copy isavailable.
Clinical indicatorsIdentifying patients for ACP discussions:disease specific clinical indicatorsRenal DiseaseClinical IndicatorsCommencement of dialysisin End Stage Kidney Diseasepatients with poor functionalstatus.Stage 4 or 5 Chronic KidneyDisease (CKD) whosecondition is deteriorating withat least 2 of the indicatorsbelow:4Patient for whom thesurprise question isapplicable (refer to page 4)Patients choosing the‘no dialysis’ option,discontinuing dialysis or notopting for dialysis if theirtransplant has failedPatients with difficultphysical symptoms orpsychological symptomsdespite optimal toleratedrenal replacement therapySymptomatic RenalFailure – nausea andvomiting, anorexia, pruritus,reduced functional status,intractable fluid overloadFailure of multiple vascularaccess and/or modalities forrenal replacement therapyDeliberate non-compliancewith treatment.Examples of issues to considerIs the patient aware of the stagesof kidney failure (Stage 3 – 5)?– Stage 3: moderate decrease in kidneyfunction– Stage 4: severe decrease in kidneyfunction– Stage 5: end stage kidney disease.What does the patient know about theoptions for both haemodialysis andperitoneal dialysis?Are they aware of the benefits andburdens of each choice?Are patients aware that they may choosenot to start dialysis and be conservativelymanaged instead?Are they aware of what this will involve,how will they be managed, and what arethe implications?Dialysis:– Does the patient know that they canwithdraw from dialysis at any time theychoose?– What action would they want takenshould their vascular access fail?– What do they understand regarding theoutcome when they opt either for notstarting or withdrawing from dialysis?– Has the patient been on home therapythat has now failed and does not wishto commence hospital haemodialysis?Transplantation:– Are they suitable for, or considering,transplantation?– Is the patient’s transplant failing andhave they stated that they do not wishto return to dialysis treatments? Whatis their understanding of what willhappen?11
Advance Care PlanningChronic Lung ConditionClinical IndicatorsFEV1 25% predicted8Weight loss (Body Mass Indexbelow 18)8Respiratory failure (PaCO2 50mmHg or 6.7 kPa)8Right sided heart failure8Worsening shortness ofbreath8Pulmonary hypertension.12Examples of Issues to ConsiderDoes the patient have any co-morbiditiesassociated with their Chronic LungCondition (e.g. Ischaemic Heart Disease(IHD), osteoporosis, depression, diabetes,glaucoma and sleep disorders)?4What is their understanding of their qualityof life, future care and treatment options?What type of treatment or care would thepatient like during acute exacerbations oftheir Chronic Lung Condition?Where would they like to be cared for?(e.g. hospital/community)?Are they aware that there may be optionsother than hospital admission(e.g. Hospital in the Home (HITH),Hospital at the Home (HATH))?Are they aware of the option forventilatory support (on exacerbation ofChronic Lung Condition)?Do they understand the differencebetween invasive and non-invasiveventilatory support during treatment fortheir Chronic Lung Condition? Whatare the patient’s views on these types ofventilation?If the patient’s breathing deteriorated tothe point of needing ventilatory support,would they accept this?What are the implications for the patient’scare if they choose to limit, withhold orwithdraw ventilatory support in the future?What are the implications if they refuseadmission to hospital?
Clinical indicatorsHeart FailureClinical IndicatorsHeart failure with symptomsnot responding to optimaltherapyRepeated number ofhospitalisations with heartfailure symptoms4Experiencing multiple shocksfrom cardiac devices2The typical trajectory of heartfailure compared to a terminalmalignancy.9Examples of issues to considerWhat does the patient understand aboutthe progression of heart failure?Are they and their family/carers aware ofthe unpredictability of this and how it mayimpact on decision-making?Where would they want to be treated inthe event of an exacerbation?Sometimes all available medication/therapy does not make the patient feelbetter or relieve the symptoms of theirheart failure (and other co-morbidities).For example, shortness of breath, waterretention and fatigue. What would be theirgoals for care at this time?Which symptoms bother them most?Electronic device implantations aresometimes used for patients diagnosedwith heart failure. Would they acceptsuch a device? What do they understandto be the benefits and burdens of thesedevices (e.g. the need for removal prior tocremation)?If the patient has an implantable device,are they aware of the impact this mayhave on their care at the end-of-life? Forexample, an Implantable CardioverterDefibrillator (ICD) can be deactivated atthe end of life to prevent prolonging thedying process.10 Do they wish to discussthis with their specialist?Transplantation – this issue may berelevant for a small number of patientswith advanced heart failure. Is thissomething the patient has thought about?Do they have any strong views on this?13
Advance Care PlanningCancerClinical IndicatorsMetastatic Cancer4Deteriorating functionalability (if more than 50% timespent in bed/lying down 3months4,11Cancer Prognosis toolsavailable e.g. PiPs, Pap,PPI, PPS414Examples of issues to considerWhat is the patient’s understanding oftheir cancer and their stage of disease?Does the patient understand whatis meant by primary and secondary/metastatic cancer?Metastatic cancer means the cancerhas spread to other organsCuring the cancer might now be moredifficultDoes the patient know if their treatmentis curative or palliative?Does the patient think it more importantto live long or to live well?Does the patient know they can chooseto stop treatment?Do they understand what will happenif they choose to stop treatment?Is the patient aware of the supportavailable as their disease progresses?What are their greatest concerns/fears?How much control do they want tomaintain over what happens to them?Who can assist/support the patient withtheir decision making?
Clinical indicatorsGeneral Neurological DiseaseClinical IndicatorsGeneral NeurologicalDiseaseProgressivedeterioration inphysical and/orcognitive functiondespite optimaltherapyPredominantlybed-bound requiringassistance with ADL/self careSwallowing problems(dysphagia) leadingto recurrentaspirationpneumonia, sepsis,breathlessness orrespiratory failureSpeech problems:increasing difficultyin communication,dysphasia.Difficulties withnutrition/ hydration.StrokePersistentvegetativeor minimalconscious state ordense paralysisMedicalcomplicationsLack ofimprovementwithin 3 monthsof onsetCognitiveimpairment/ poststroke dementia.DementiaThere are many underlyingconditions which may leadto degrees of dementia andthese should be taken intoaccount. Triggers to considerthat indicate that someone isentering a later stage are:4Unable to walk withoutassistance andUrinary and faecal incontinenceandNo consistently meaningfulconversation andUnable to do Activities of DailyLiving (ADL)Barthel score 3.Plus any of the following:Weight lossUrinary tract InfectionSevere pressures sores –stage three or fourRecurrent feverReduced oral intakeAspiration pneumonia.Of all people experiencing a stroke, one third will die in the first 12 months1215
Advance Care PlanningNeurological DiseaseExamples of Issues to ConsiderGeneral Neurological Disease, Stroke, DementiaWhat are the main fears or concerns (e.g. loss of communication, lossof body control)?How can they optimise their functional independence?Where do they want to live? What has to be done to address these wishes?Are they aware of available support (e.g. Home Help)?Carer issues – what will happen if the person’s primary carer needshospitalisation or is no longer able to assist with care? How can the personplan for this?What are the patient’s views on artificial feeding and nutrition(e.g. nasogastric, PEG/gastrostomy insertion)?Do they have any opinions/thoughts on interventions related to treatingcomplications such as pneumonia/chest infections or urinary tract infections(e.g. using intravenous antibiotics)?It is vital that discussions with individuals living with dementia are started earlyto ensure that whilst they have mental capacity they can discuss how they wouldlike the later stages managed.416
Clinical indicatorsAppendix 1: Mental Capacity AssessmentCentral to the ACP process (and essential for creating a valid AHD or appointing anEnduring Guardian) is the question of capacity.In WA, the legal position assumes that an individual aged over 18 years hascapacity unless otherwise proven.In the context of Advance Care Planning, capacity relates to the ability to makedecisions about medical treatment now and in the future.Some guiding questions which may assist in determining whether a person hascapacity include:Does the patient possess adequate information processing skills (attention,absorption, intention and linear thinking) for the decision at hand?Is there understanding of the nature of the issue, why it’s an issue and canthey articulate this?Do they know the relevant facts?Is there understanding of options and the risks and benefits of each option?Is there ability to compare the choices at hand and arrive at a decision througha reasoned process?Is the patient able to communicate their decision and reasoning process?Is there an absence of coercion?Is there a mental disturbance which distorts thinking in relation to the specificmatter in question?Is the patient depressed, in pain, or have other symptoms which may bealtering their decision-making abilities?Finally, it is also desirable but not essential if the patient demonstrates consistencyof views over time.17
Advance Care PlanningAppendix 2: The Australia – modified KarnofskyPerformance Status (AKPS)13Score (%)100Australia-modified Karnofsky (AKPS)Normal; no complaints; no evidence of disease90Able to carry on normal activity; minor signs or symptoms80Normal activity with effort; some signs or symptoms of disease70Cares for self; unable to carry on normal activity or to do activework60Requires occasional assistance but is able to care for most of hisneeds50Requires considerable assistance and frequent medical care40In bed more than 50% of the time30Almost completely bedfast20Totally bedfast and requiring extensive nursing care byprofessionals and/or family10Comatose or barely arousable0DeadKPS 50%18
Clinical indicatorsGlossaryAdvance Care Planning (ACP)Advance care planning is an ongoing discussion between an individual, their carers/family and their health care team about their values, beliefs, treatment and careoptions; in particular, their wishes for future care should they no longer be able to doso at the time decisions are needed. Ideally these decisions should be documentedin an Advance Health Directive.Advance Health Directive (AHD)An Advance Health Directive is a legal document that is completed using a formwhich contains a person’s decisions about future treatment in anticipation of atime when they may be unable to make reasonable judgments for him/herself. Avalid AHD is legally binding and documents treatment decisions in which a personconsents or refuses consent to future treatment according to specific circumstances.A valid AHD must be in the form or substantially in the form prescribed by theregulations.14CapacityCapacity is the cognitive ability to understand and appreciate the context, choicesand consequences of our decisions. It is also a person’s performance on measuresof decision making ability. On the other hand, competency is determined by courtsand tribunals and is the judgement that a person’s capacity is adequate to make thedecision in question. Competency is a legal construct and capacity is a clinical one.End-of-Life CarePatients are ‘approaching the end of life’ when they are likely to die within the next12 months, as described by The Gold Standards Framework, United Kingdom.4 Thisincludes people whose death is imminent (expected within a few hours or days) andthose with:advanced, progressive, incurable conditionsgeneral frailty and co-existing conditions that mean they are expected to diewithin 12 monthsexisting conditions if they are at risk of dying from a sudden acute crisis in theirconditionlife-threatening acute conditions caused by sudden catastrophic events.Enduring Power of Attorney (EPA)An enduring power of attorney is a legal agreement that enables a person toappoint a trusted person - or people - to make financial and property decisionson their behalf. An enduring power of attorney is an agreement made by choicethat can be executed by anyone over the age of 18, with capacity.19
Advance Care PlanningEnduring Power of Guardianship (EPG)An Enduring Power of Guardianship is a document in which a person nominates anEnduring Guardian to make personal, lifestyle and treatment decisions on their behalfin the event that they are unable to make reasonable judgments about these mattersin the future.14 An EPG is different from an Enduring Power of Attorney (EPA), whichrelates to financial and property matters.14Palliative CarePalliative care is an approach that aims to improve the quality of life of patients and theirfamilies facing the problems associated with life-threatening illness. This is achievedthrough the prevention and relief of suffering by means of the early identification,impeccable assessment and treatment of pain and other physical, psychosocial andspiritual problems.15Proxy or SubstituteThe individual the person nominates to assist in decision-making on his/her behalfin the future, should the person be unable to participate in the decision-makingprocess themselves. The individual proxy or substitute does not have to be next-ofkin or a family member.References are available at www.health.wa.gov.au/advancehealthdirective20
Clinical indicatorsReferences1Fischer S, Gozansky W, Sauaia A, Min S, Kutner J, Kramer A. A practical toolto identify patients who may benefit from a palliative approach: the CARINGcriteria. J Pain Symptom Manage. 2006 Apr;31(4):285-92.2Connolly M, Beattie J, Walker D, Dancy M. End of life care in heart failure:a framework for implementation. Leicester, UK: National Health ServiceImprovement and National End of Life Care Programme; 2010.3Stuart B, Herbst L, Kinzbrunner B, et al. Medical guidelines for determiningprognosis in selected non-cancer diseases: the National Hospice Organization.Hosp J. 1996;11(2):47-63.4The Gold Standards Framework [Internet]. Shrewsbury, UK: GFS Centre CIC;2012. GSF Prognostic Indicator guidance (4th ed.); 2011 September [cited 2012Apr 23]; Available from: 5Clayton J, Hancock K, Butow P, Tattersall M, Currow D. Clinical practiceguidelines for communicating prognosis and end-of-life issues with adultsin the advanced stages of a life-limiting illness, and their caregivers. MJA.2007;186(12Suppl):S77-S108.6Karel MJ, Powell J, Cantor MD. Using a values discussion guide to facilitatecommunication in advance care planning. Patient Educ Couns. 2004Oct;55(1):22-31.7Austin Health. Respecting patient choices: an Australian Advance CarePlanning Program: consultant’s manual. Western Australian Edition.Melbourne:Austin Health; 20068Department of Health, Western Australia. Chronic Obstructive PulmonaryDisease model of care. Perth: Health Networks Branch, Department of Health,Western Australia; 2008.9Heart Foundation of Australia [Internet]. Canberra, ACT: National HeartFoundation of Australia; c2011. National Heart Foundation of Australia and theCardiac Society of Australia and New Zealand (Chronic Heart Failure GuidelinesExpert Writing Panel): guidelines for the prevention, detection and managementof chronic heart failure in Australia; [updated October 2011; cited 2012 Apr 23].Available from: cuments/Chronic Heart Failure Guidelines 2011.pdf10 Beattie J, Connolly M. Managing the end-game: palliative care for advancedheart failure. Heart Improvement eBulletin [Internet]. 2009 May 5 [cited 2012 Apr23];112. Available from: /ViewDocument.aspx?path d%20game%20article.pdf21
Advance Care Planning11 Weissmen, D. Fast fact and concepts #13: determining prognosis in advancedcancer. (2nd ed.). End-of-Life / Palliative Education Resource Centre. [Internet].2005 June [cited 2012 Apr 23]; Available /ff 013.htm12 Department of Health Western Australia. Model of Stroke Care for WesternAustralia. Perth: Department of Health Western Australia delsofcare/docs/Stroke Modelof Care.pdfDepartment of Health, Western Australia. Motor Neurone Disease servicesfor Western Australia. Perth: Health Networks Branch, Department of Health,Western Australia; 2008.13 Abernethy A, Shelby-James T, Fazekas B, Woods D, Currow D. The Australiamodified Karnofsky Performance Status (AKPS) scale: a revised scale forcontemporary palliative care clinical practice [ISRCTN81117481]. BMCPalliative Care [Internet]. 2005 Nov 12 [cited 2012 Apr 23];4(7). Available from:http://www.biomedcentral.com/1472-684X/4/714 Department of Health, Western Australia. A guide for health professionals to theActs Amendment (Consent to Medical Treatment) Act 2008. Perth: Departmentof Health, Western Australia; 2010.15 World Health Organization. [Internet]. Geneva, Switz. WHO; 2012. WHOdefinition of palliative care; 2012. [cited 2012 Apr 23]; Available on/en/22
AppendixThis document can be made availableProduced by WA Cancer and Palliative Care Network Department of Health 2012HP12505 OCT’12in alternative formats on request fora person with a disability.25
Planning A step-by-step guide for health care professionals assisting patients with chronic conditions to plan for care towards end of life. Advance Care Planning 2 Contents Advance Care Planning Process Introduction 3 Identifying patients for ACP discussions: triggers and prompts 4 Identifying patients for ACP discussions: generic clinical .
identify and address the consumer's needs, goals, and preferences, including advance care planning and end-of-life planning, if the consumer wishes. This guide aims to support the implementation of advance care planning and Advance Care Directives in aged care as well as compliance with relevant standards. The guide explains why advance care
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The decision to start advance care planning is a personal one. It can be useful to start by thinking about other people's experiences and what they have found helpful about advance care planning. Figure 1 provides some examples. Figure 1. Examples of how advance care planning can help during different life experiences
care planning for this population. Advance care planning allows adults to understand and share their personal val-ues and preferences regarding future care []. Advance 3 care planning is relevant to everyone, irrespective of age or health status, to ensure that people's care wishes are clearly documented ahead of time. Having these conver-
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guide about 'Advance Decisions' is available which is a legal way to refuse treatments that may be offered to you in the future (Section 5). An Advance Decision is different to an advance statement. 4 Advance Care Planning Guide: Planning for Your Care and Wellbeing
Advance Care Planning: A guide for the New Zealand health care workforce 1 1 Introduction Advance Care Planning (ACP) is a concept that was introduced internationally in the late 1980s but has only gained momentum in New Zealand in recent years. ACP assists in the provision of quality health care and treatment and is becoming increasingly .
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