Advance care planning is a process of planning for future health and personal care whereby a person’s values, beliefs and preferences are identified so they can guide decision-making at a future time when the resident is unable to communicate their decisions ¹

When I started working 10 years ago as a Nurse Practitioner at Karingal Gardens, a 100-bed high care facility in Taree NSW, advance care planning was only just being talked about in NSW. Karingal Gardens is one of three residential aged care facilities in the Bushland Health Group.

With new admissions from our local hospital, we began to receive copies of documented conversations about the residents’ and families’ wishes regarding their future goals of care. After I attended a local workshop on this topic, the Director of Care adopted this concept and asked me to develop advance care planning policy and procedures for the Bushland Health Group RACFs. I began by requesting copies of any advance care planning documents from the GPs for their residents. There were none!

Next we had to identify the ‘person responsible’ who would be involved in these discussions if the resident was not capable of making informed decisions. This is the substitute decision-maker in NSW for those unable to make informed decisions, it may or may not be ‘next of kin’. We obtained information pamphlets from the NCAT NSW website about identifying this person. This information was then explained to new residents and families so the ‘person responsible’ was identified and acknowledged. Whenever families had doubts about the suitability of a person identified in this role, they were given the option of pursuing this with the Guardianship Board. This person’s name became the first person of contact in our documentation system.

I began advance care planning discussions with our residents and their families beginning with each new admission until all 100 residents had an Advance Care Plan (ACP). The conversations were documented with all parties present signing the document. Sometimes these conversations happened by phone and documents were faxed or emailed for the signatures.

In NSW there is still no official Advance Care Directive or Advance Care Plan form that must be used so I researched the different forms being used in NSW RACFs and included the legalised QLD documents. I based our form on the Plan of Care Form on the Advance Care Planning Australia website and added a ‘Comments’ section where the resident could add any modifications or additions to their wishes. The resident, ‘person responsible’, other family members and a staff member all sign this document. Once a resident has a completed ACP, a yellow sticker is placed on the spine of their resident folder as a staff alert. This whole process was considered and approved by our Palliative Care Steering Committee.

Next I developed a ‘Decision Aid for Advanced Care Planning’ brochure which gives information on considering disease trajectories, the signs of a 6-month prognosis and statistics on the results of ringing 000 for a cardiac arrest. It also includes facts on the effects of hospitalisation on residents with dementia. The brochure is explained if needed and is displayed in our foyers for visitors to read.

After this process was firmly embedded at Karingal Gardens, I gave formal and ongoing informal education to the RNs from all three facilities in the Bushland Health Group. It is now the responsibility of the admitting RN to introduce the topic of advance care planning to residents and families on admission. Only complex cases are now referred to me.

RNs follow the ACP when a resident’s health deteriorates and inform the GPs of the residents’ personal goals of care before ordering treatment. The GPs now sign the ACP to ensure that they are aware of the residents’ wishes and to prompt them to discuss any treatment which may be futile. A copy of the ACP is always sent to the Emergency Department with residents, so their wishes are known and followed. All ACPs are reviewed after hospitalisation or an acute illness, once a 6-month prognosis is identified and whenever the residents or families wish.

Our ACPs are the foundation of all care leading up to and including palliative care at end of life. This process develops trust in our organisation as residents and families are assured their wishes will be respected and followed and that appropriate care is given. In 2017, our Advance Care Planning process was recognised as part of our core palliative care services when our organisation won the Inaugural National Award for Excellence and Innovation for our Palliative Approach: Nurse Practitioner Model.

If you’d like to learn more about this topic go to the Health Professional Options of the CareSearch Education Section and under eLearning, click on Advance Care Planning.

References

1. Commonwealth of Australia. A National Framework for Advance Care Directives. Australian Government Department of Health and Ageing, Canberra, 2011.

Sharyn Speakman, Nurse Practitioner - Older People Nursing, Bushland Health Group