Advance Care Planning (ACP) or Advance Health Directives (AHD) to Older People is recommended in the following circumstances:
- The person has one or more significant medical conditions.
- The person has a measurable change in their level of function/requires an increased level of support to perform their daily activities
- The person has increased hospital admissions in the past 12 months due to deterioration associated with their underlying condition(s)
- The person has been diagnosed with a new significant or terminal medical condition
- The person has been diagnosed with a progressive neurological condition and is at risk of losing their mental capacity in the next 12 months.
- The person is likely to transition into residential aged care in the coming 12 months
- When the answer is “No” to the “Surprise Question” – Would you be surprised if this person died within the next 12 months (www.goldstandardsframework.org.uk/cd-content/uploads/files/General%20Files/Prognostic%20Indicator%20Guidance%20October%202011.pdf)?
- The person indicates that they would like to talk about their future health care and medical treatment.
It is recommended that ACP conversations are integrated into routine health assessments for the older person which include the 75+ health assessment and the Indigenous Health Assessment.
WA Health have just released the new Advance Health Directive Form and updated ACP resources – these can be accessed here
Starting the conversation can be difficult and it might be helpful to use the four-step model for ACP developed by Palliative Care WA (PCWA) which can be accessed here
The Advance Care HealthPathway has a number of useful resources.
The importance of ACP conversations cannot be understated. Research has demonstrated that:
- ACP resulted in a significant reduction in the rate of hospitalisations for people in their last year of life and for those admitted to hospital, their length of stay was much reduced.
- ACP reduced the probability of an ICU admission in the last six months of life.
The role of GPs in supporting the uptake of ACP for older people will support them to make important choices about their future care and will better prepare their families for bereavement. See the Health Professionals Guide to Advance Care Planning in Western Australia and the End of Life and Palliative Care Education and Training Framework for more information.
Information on MBS billing items related to ACP activities can be found here