My Wishes
Advance Care Planning Program

Healthcare and community staff, including GPs


All healthcare and community care workers should have at least some knowledge of advance care planning (ACP).

All clinical staff with a direct caring role for patients and clients, medical records staff and patient-related administrative staff such as ward clerks and receptionists should understand what ACP is and be able to explain ACP to patients in general terms.
Staff with a patient or client management role, including doctors, registered nurses, social workers, other allied health staff, and community care staff should: take responsibility for knowing if a patient has an ACP; be able to initiate and facilitate discussions with a patient and/or their substitute decision makers; fully document outcomes of ACP discussions in the relevant format for their own organisation; and ensure any ACP is referred to and used in any subsequent care planning.
General Practitioners (GPs) have a central role in ACP because they often care for many people with chronic and life-limiting illnesses. They also often have trusting long-term relations with their patients, which allows them to discuss the type of personal issues that are involved in ACP.
Below you will find a number of resources that healthcare and community care staff, including GPs, can use to develop a more structured and systematic approach to ACP.
A one-page leaflet introducing the concept of ACP and some of its benefits. This is suitable for general distribution – such as in GP surgeries, community organisations, hospitals or residential care facilities.
A four-page brochure that provides an introduction to many of the issues involved in ACP relevant to staff of hospitals and community health services.
A four-page brochure that provides an introduction to many of the issues involved in ACP tailored to the needs of GPs.
A four-page brochure that provides a general introduction to many of the issues involved in ACP. This may be suitable for GPs or healthcare staff to give to patients and/or the patient’s family as part of discussions about their ongoing care.
A model that explains the range of practices that facilities may take in terms of how routinely and systematically they approach ACP. It can be used as a quality improvement tool to help facility managers understand their current practice and look at possible areas for improvement.
A comprehensive outline to assist staff in setting up and conducting ACP discussions. It takes the reader through each step in the process, identifies key issues and provides possible questions or prompts. The guidelines can be a used as a training tool or reference for staff involved in ACP.
Outlines four broad areas of competence for staff related to ACP: explain the nature and benefits of ACP; initiate and manage ACP discussions; follow-up outcomes from ACP discussions; and take responsibility for maintaining ACP systems.
This page outlines some key issues about documenting your wishes and has forms developed as part of the My Wishes program.
Information sheets related to chronic and end-of-life care
Documents that provide information that might help patients or their family understand the progression of chronic disease and end-of-life care. It is recommended that these information sheets be given to patients or family as part of a discussion with them rather than being distributed in isolation
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


© 2016 South Western Sydney Local Health District
Last Updated: 03 July, 2013
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