Advance care planning will often involve the following components:
- Discussions about prognosis and possible future scenarios and patient concerns
- Appointment of a Substitute Decision Maker(s) and their involvement in initial and subsequent ongoing documented discussions
- Reaching consensus on current and possible future ‘goals of care’.
- These goals may be supported by a statement describing the reasoning underpinning the choices a patient has made
- Discussing choices around preferred place of care during their illness and in the ‘terminal phase’
- Documenting these discussions in an easily retrievable format, held by the patient, their Substitute Decision Maker, their family and GP
All of the above components can be strengthened if the patient’s primary carers and family are involved in some way.
Below is a brief pro-forma Advanced care directive from Tasmania and a substantially more detailed on from NSW.