Advance Care Planning

Advance care planning (ACP) is a voluntary process of planning for future health and personal care whereby the person’s values, beliefs and preferences are made known to guide decision-making at a future time when that person cannot make or communicate their decisions.

In Western Australia, ACP can be completed by anyone over 18 years of age who has decision-making capacity. Find out more about ACP and the role of health professionals (WA Health).

The ACP process (HealthyWA).

• Health professional guide to ACP in WA (WA Health)
• Your guide to ACP in WA: workbook (WA Health)
• A guide to making an Advance Health Directive in WA (WA Health)

• Advance Health Directive (WA Health)
• Enduring Power of Guardianship (WA Government)
• Values and Preferences Form (WA Health)
• Values and Preferences Statement for a Person With Impaired Decision-Making Capacity (ACP Australia)

• Relevant legislation in WA and their implications for health professionals (Table 1. Health Professional Guide to ACP in WA – WA Health)

ELLC training program to support clinical practice (Palliative Care Education Collaborative)

GPs develop ongoing and trusted relationships with their patients and are well positioned to initiate and promote ACP. General practice staff should aim to incorporate ACP as part of routine health care.

There will be opportunities to proactively discuss ACP during consultations that include the following:

• 75 + health assessment.
• Chronic condition management plan.
• A patient with a life-limiting illness.
• A patient at risk of losing capacity through diagnosis of dementia or another progressive neurological condition.
• A patient with a change in care needs such as being admitted to a residential aged care home.

• General practice resources (The Advance Project)
• ACP training and resources (WA Health)
• Program of Experience in the Palliative Approach (PEPA)
• Palliative and Supportive Care Education (PaSCE WA)
• ACP core training guide (Practice Assist)
• ACP implementation plan checklist (Practice Assist)
• ACP process – routine health assessments and return appointment (Practice Assist)
• ACP practice nurse script – health assessments (Practice Assist)

• ACP pathway (Clinician Assist WA)
• ACP Position Statement (RACGP)
• ACP in Western Australia (WA Health)
• Planned palliative care MBS items fact sheet (Practice Assist)

Reception staff should scan the patient’s completed ACP document and upload it to the practice’s clinical software and My Health Record.

To find out more about uploading an ACP document, refer to the following resources:

• Uploading an ACP document to BP Premier and My Health Record (Practice Assist)
• Storing ACP documents in Best Practice (Practice Assist)
• Reception staff script – ACP document storage (Practice Assist)

After uploading, return the completed ACP document to the patient and advise them to keep it in a safe place and share copies with people they trust and feel comfortable with, including the following:

• Family, carer and significant others.
• Enduring guardian.
• Residential aged care home.
• Other specialist(s) and/or health professionals.
• Local hospital .

Patients can also upload their ACP document to My Health Record:

• Patient instructions to upload ACP to My Health Record (digitalhealth.gov.au)

• End-of-life planning mini audit (caring@home)
• Quality Improvement (QI) Tool Kit (Practice Assist)
• PDSA – Improving completion of ACP training in general practice (Practice Assist)
• PDSA – Improve data quality of ACP documentation in patient records (Practice Assist)
• PDSA – Implementing ACP within health assessments (Practice Assist)

• ACP brochure for the WA Aboriginal community (WA Health)
• Taking Care of Dying Time (Video – WA Health training)
• Taking Care of Dying Time – extended version (Video – WA Health training)
• Journey To Dreaming Toolkit (Aboriginal Health and Medical Research Council of NSW)
• Supporting Palliative Care for Aboriginal and Torres Strait Islander Communities (Gwandalan)

• Translated ACP resources (HealthyWA)
• Decision making tree for engaging an interpreter (WA Health)
• Language services (WA Health)
• ACP: Thinking Ahead Before Something Happens (Deaf Connect)
• Sensory loss – Quick guides and Auslan videos (Palliative Care WA)

LGBTIQ+ Inclusive Palliative Care eLearning (LGBTIQ+ Health Australia)

Department of Health WA ACP Information Line

• Get in touch for general queries and to order free resources (e.g. Advance Health Directives and Values and Preferences forms).
• Phone: 9222 2300
• Email: ACP@health.wa.gov.au

• ACP Support Service (Palliative Care WA)

• Office of the Public Advocate (WA Government)
• Enduring Power of Guardianship (WA Government)
• Enduring Power of Attorney (WA Government)

• ACP for GPs (ACP Australia)
• A nurse introduces ACP to her patient (ACP Australia)
• A doctor and patient discuss ACP (ACP Australia)
• Love is not enough (ACP Australia)

• VAD information (WA Health)

• VAD and ACP (Video)