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Advance care planning for healthcare providers

Key points about advance care planning

This page contains information about advance care planning for healthcare providers.
Find information on advance care planning, shared goals of care, and resources for further reading.

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Advance care planning is the process of thinking, talking, planning, sharing and reviewing what matters to a patient, it is a complementary process to a shared goals of care discussion. Advance care planning may result in the completion of an advance care plan, these plans are enduring and can traverse several episodes of care. They provide a good framework from which to start discussions about treatment planning. Advance care plans can inform a shared goals of care discussion which is actually a focused advance care planning conversation that relates to an episode of care.

Shared goals of care are when the patient, their family and whānau, and clinicians explore the patient’s values along with the care and treatment options available and agree the goal of care for the current admission if the patient deteriorates. Essentially it is a targeted advance care planning conversation for an episode of care.

Having a shared goals of care discussion should take place before an episode of deterioration so everyone can fully engage in the process. Shared goals of care discussions are documented on a shared goals of care form. A shared decision-making process between the patient and the clinical team. 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.

Having a shared goals of care discussion should prompt thinking and talking about advance care planning for both the clinician and the patient. Read more about shared goals of care.(external link)

Shared goals of care forms

Shared goals of care forms are available for hospitals, aged residential care facilities and for COVID-19 treatment.

Shared goals of care plan (777)(external link) HQSC, NZ
Shared goals of care plan (MET)(external link) HQSC, NZ
Shared goals of care plan (RRT)(external link) HQSC, NZ
Shared goals of care plan for ARC(external link) HQSC, NZ

Advanced Care Planning has a one-day workshop on Thursday, 13 July 2023, open to all health workers. It will cover the benefits of ACP, the legal framework with case studies, communication skills and documentation practice.

The HQSC ACP online learning(external link) is a great place to start and will set you up before attending. Click here(external link) to enrol or email programme lead Cheryl Calvert.

Guidelines and articles

Navigating the last days of life: a general practice perspective(external link) BPAC, NZ, 2023
Worried about COVID-19? In uncertain times it's good to make a plan(external link) Health Quality & Safety Commission, NZ
Serious illness conversation guide(external link) Health Quality & Safety Commission, NZ
Letting go – what should medicine do when it can't save your life?(external link) Dr Atual Gawande, The New Yorker, 2 August, 2010

Books

With the End in Mind: Dying, Death, and Wisdom in an Age of Denial(external link) Kathryn Mannix, William Collins, 2018
Dr Kathryn Mannix has studied and practiced palliative care for thirty years. In ‘With the End in Mind’, she shares beautifully crafted stories from a lifetime of caring for the dying, and makes a compelling case for the therapeutic power of approaching death not with trepidation, but with openness, clarity, and understanding.
Listen: A powerful new book about life, death, relationships, mental health and how to talk about what matters(external link) Kathryn Mannix, William Collins, 2021
Most of us have a conversation we’re avoiding. From the bestselling author of ‘With the End in Mind’, this is a book about the conversations that matter and how to have them better – more honestly, more confidently and without regret.
Being mortal – medicine and what matters in the end(external link) Dr Atul Gawande, Metropolitan Books, 2014
"Medicine has triumphed in modern times, transforming the dangers of childbirth, injury, and disease from harrowing to manageable. But when it comes to the inescapable realities of aging and death, what medicine can do often runs counter to what it should ..."

e-learning resources

Advance care planning eLearning (Level 1 training)(external link)

Comprises 4 e-learning modules to help healthcare workers understand and explain the process and benefits of advance care planning
Also, covers the legal basis for ACP
Certificate of completion
Prerequisite for anyone going on to undertake the Level Two training.
Created by the ACP Cooperative NZ
View online(external link)

Advance care planning training manual(external link) Health Quality & Safety Commission, NZ
Advance care planning training workshops Health Quality & Safety Commission training(external link)
Considering your own future health care(external link) Advance Care Planning Cooperative, NZ Advance care planning online module: considering your own future health care is for everyone working in healthcare, and for any other interested people.

Additional websites

Age Concern NZ(external link) wide range of resources including resources around enduring powers of attorney
Hospice NZ(external link) Hospice NZ exists to lead the hospice movement to ensure that every New Zealander has access to quality palliative care
Advance care planning – a guide for the NZ health care workforce(external link) Health New Zealand | Te Whatu Ora

International websites

Advance care planning is becoming increasingly popular in many countries around the world.

NOTE: Legal frameworks differ from New Zealand so make sure to check what applies to your country.

Conversation Project(external link) US
Dying Matters(external link) UK
Speak Up(external link) Canada