Documenting an advance care plan

myWishes

You can put your wishes about future healthcare in writing by completing an advance care plan (ACP). This will sometimes be called an advance care directive or living will.

You can make up your own document or else use one of a number of forms that have been developed for this purpose. Many of these forms allow you to document your beliefs and values as well as giving both general and specific instructions around treatment areas such as resuscitation, use of artificial feeding, artificial breathing support and palliative care.

Guidelines produced by NSW Health support the use of ACPs if they follow the four principles of being specific, current, completed by someone with capacity and witnessed.

Not everyone feels the need to complete a written document. However, they are particularly relevant if you have strong specific views about how you want to be treated or if you are concerned people making decisions for you won’t be clear about your wishes.

While there are a number of useful forms available to document an ACP, the Sydney South West Area Health Service has developed three forms as part of their medical records system. These may be completed by you or your substitute decison-maker in consultation with an Area Health Service staff member and included in your medical records. Alternatively, your or your substitute decision-maker can send a completed form to the Medical Records Department of your local hospital with a covering note requesting the form be included in your medical records.

If you do complete an ACP document, it is important that you give copies to people such as your GP, medical specialists and family members who may have to make decisions on your behalf in the future.

Statement of Values and Wishes – Completed by the Patient

Using this form will help you to engage in a discussion with your loved ones about your values and wishes. It will also help to provide some evidence of your wishes if difficult decisions need to be made about your care in circumstances where you cannot make these decisions for yourself.

The form can be used in two ways:

In a community setting, a person may complete a form and request that it be included in their medical record. While it is not technically necessary, it is recommended that the person complete the form in consultation with their GP or Specialist Doctor and have the form witnessed by another person. This will reduce the likelihood that people will later question the validity of the document on the basis of the person not being fully informed or competent.
In a healthcare setting – such as a hospital, outpatient clinic, specialist consulting rooms, community health centre or aged care facility – the form can be used as a discussion guide between an individual and a Doctor or other Healthworker who is involved in the person’s care. In this case, the Doctor or Healthworker can explain issues like prognosis and treatment options that will help the individual make fully informed choices in completing the form. In this case the Doctor or other Healthworker can sign the form to indicate they have participated in a discussion with the person.

Statement of Values and Wishes – Completed on behalf of the Patient by their Person Responsible

This form is used when the person concerned is no longer in a position to make decisions for themselves and it needs to be completed by their substitute decision-maker(s). Completing the form will help the family and loved ones to reflect on what the person’s wishes would be. It will also help to provide some evidence of the person’s wishes if difficult decisions need to be made about their care at some time in the future.

A Doctor needs to complete this form with the Person Responsible or at least be part of the discussion and verify that the patient does not have capacity to provide their own consent. The Doctor and other Healthworker who has assisted in completing the form need to date and sign it, along with the Person Responsible. The form should be reviewed and updated if necessary each time the person is admitted to hospital.

Record of Advance Care Planning Discussions

This form is meant to be used by hospitals or residential aged care facilities. Unlike the other forms, that have a number of questions to be answered, this is basically a blank form where staff can record the outcomes of any discussions related to ACP. By badging the form as part of this program, and locating it with other ACP-related documents at the front of the patient’s record, it will make this information much more accessible than when comments about ACP are scattered throughout the patient’s medical record.

To get more detailed information about issues such as Power of Attorney, Enduring Guardianship, substitute decision making and other ACP programs, go to Further Information