Advance care planning for healthcare providers

Advance care planning is the process of thinking about, talking about your values and goals and what your preferences are for current and future health care. It helps people understand what the future might hold and to say what health care they would or would not want, including at their end-of-life.

There are a number of tools clinicians can use to support the advance care planning process including advance care planning guides, advance care plans, advance directives, shared goals of care and serious illness conversations. Find out more from the clinician pages on the national advance care planning website(external link). 

Advance care plans

An advance care plan is a document that captures what is important to the person and outlines the care and treatment they would or would not want if they were unable to communicate for themselves. Advance care plans have legal standing and will often include an advance directive. 

An advance directive is consent or refusal to a specific treatment offered in the future when the person no longer has capacity. If it's valid – the person was competent and informed when the directive was created, undertook the process voluntarily, and intended it to apply to the current situation – an advance directive is legally binding.

There is online training(external link) and a one-day workshop available to help clinicians gain confidence in advance care planning processes and conversations and advance care plan and advance directive documentation. 

Please refer to your local HealthPathways advance care planning page for information about how to record and share advance care plans in your area. 

Shared goals of care

Shared goals of care are when clinicians, patients and whānau explore patient’s values, the care and treatment options available and agree the goal of care for the current episode of care and if the patient deteriorates. At a minimum, the overall direction for an episode of care (eg, curative, restorative, improving quality of life or comfort whilst dying) and any agreed limitations on medical treatment need to be identified.

Shared goals of care is targeted advance care planning for an episode of care. The process is led by clinicians and comprises a discussion and a decision/plan in the event of deterioration. Both the discussion and the decision are documented on a shared goals of care plan. 

There are 2 versions of the shared goals of care plan currently available:  

• Shared goals of care for hospital admissions(external link)  
• Shared goals of care for aged residential care/long term care facilities(external link)  

The Serious Illness Conversation Guide Aotearoa(external link) uses a set of patient-tested questions to support clinicians to have conversations with seriously ill people and their whānau, about what is most important to them if time were limited and/or their functional abilities were to change. The Serious Illness Conversation Guide is a useful tool to support shared goals of care discussions.

There is online training(external link) and a 3-hour training workshop available to help clinicians gain confidence in having serious illness conversation. Read more about serious illness conversations. (external link)

There are a number of online and face to face training resources(external link) available for clinicians to increase their knowledge and confidence supporting the advance care planning processes. 

Advance care planning