How to - 5 Steps

Know what you're talking about

Before you start having ACP conversations with your patients, you need to know what ACP is and who would benefit from it.

It's also a good idea to have completed your own Advance Care Planning so you know what's involved, what it feels like, and what benefit you got from doing it.

man lying on grass thinking
Know who to talk to

Advance Care Planning is for everyone, but how you raise it may well be different depending on who you are talking to. Our research found that people are thinking about it and touching on it in casual conversation, but most don’t know their preferences can make a difference and influence their own outcomes. There was also a clear message that they want their clinician to bring it up in conversation.

For a better understanding of this, you should do the eLearning module Talking About ACP and take a look at the SPICT guideline.

Think about these different opportunities and how you could raise it with patients at difference stages of their lives:

A chart showing the decline of a patients function from the onset of an incurable disease

If something unexpected occurred, are there circumstances where you would you like treatment to change to comfort? Have they thought about appointing an EPOA (health and welfare)?

Diagnosis, acute episodes. Next episode might not have such a good outcome – if things did not go well what would you want, how would you like us to care for you?

You would not be surprised if the person were to die in the next 6-12 months. Detailed Planning and documentation of treatment & care preferences

At a minimum, you need to be ready to respond to a patient who raises it with you. It is also expected that you would raise it with patients who are approaching the end of their lives, to find out what’s important to them and help give them some control over what might happen.

Look at your patient group and identify people who are at risk of dying or losing their ability to communicate permanently or temporarily within the next 6-12 months. These are the people who would immediately benefit from you having an ACP conversation.

Thinking about your future health care leaflet

Use this template
to start your thinking.

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considering your own future health care module

Advance Care Planning eLearning
Healthcare workers can now access the eLearning modules through the Advance Care Planning LMS.

Take me to the eLearning
SPICT Guidelines

SPICT Guideline
Take a look at the SPICT guideline for identifying people approaching the end of life.

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Keep the Conversation going

Advance Care Planning is not a one-off conversation. It’s a series of conversations between your patient, you, their family/whānau and any important others. Your purpose is to find out what’s important to your patient, how their beliefs and values might affect any future medical treatment and care they need, and how they’d like decisions made if they’re unable to speak for themselves.

Ideally these conversations will lead up to a written statement of their preferences for health care and end of life care, with any specific directives, so that it can be referred to if and when needed.

two ladies talking
Be aware of Barriers

There may be barriers to talking about and planning for future care - particularly care at the end of life. It is helpful to consider these barriers from both your perspective and your patients’ perspective, so that you can achieve a positive outcome.

Discussion Tips
  • It is not advisable to introduce Advance Care Planning at the same time you share a patient’s diagnosis with them.
  • If you have an agenda, do not have an Advance Care Planning conversation - remember this is not about you, it is about the patient.
  • The key contributions you can make to a person’s Advance Care Planning journey are to:
    • Encourage them to think about what is important to them
    • Encourage them to plan for future care
    • Provide the patient with the information they want about what their future health and treatment or care options might be.

Conversation Starters

Here are some conversation starters you might want to try:

  • Now would be a good time for us to talk about what’s important to you, and what you do and don’t want if you can’t speak for yourself.
  • I was wondering if you and your partner have had any conversations about what you’d want if there was a sudden health crisis or emergency…?
  • Now would be a good time for me to know more about what’s important to you about your treatment and care going forward…
  • Have you heard of Advance Care Planning? It’s where you start to think about what’s important to you about your future healthcare, and what you’d like to happen in certain circumstances.
  • While you’re still strong and able, it’s a good idea to start thinking about your future health care, and make your preferences known to your family. We call this Advance Care Planning.
  • Have you ever thought about who you would want to make decisions about your future health and treatment if you were unable to?
  • I’d like to talk to you about Advance Care Planning. This is where you think about your values and beliefs, and how you would like us to include these in how we care for you over the coming months.

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considering your own future health care module

Advance Care Planning eLearning
Healthcare workers can now access the eLearning modules through the Advance Care Planning LMS.

Take me to the eLearning
Keep a record

There is great value in any Advance Care Planning conversations that you have with your patients, but unless these are documented it may get lost.

So whenever you have an Advance Care Planning discussion, take the time to summarise and record the key points so that it is there for you or others to refer to if needed. Let your patient know that you want to keep a note of what you’ve discussed, and confirm the key points with them.

doctor talking with patient
Make a Plan

It is even better if you can encourage them to, or assist them to, complete an Advance Care Plan. The My Advance Care Planning Plan template is useful for this.

Once a patient has completed an Advance Care Plan:

  • Keep a copy on their file
  • Send a copy to other healthcare team members
  • Encourage them to share it with their family/whānau, friends and Enduring Power of Attorney (if they have one).

Talking about your future health care leaflet

My Advance Care Plan Template
Give this template to your patients, or help them to complete it.

Download Now
considering your own future health care module

Advance Care Planning eLearning
Healthcare workers can now access the eLearning modules through the Advance Care Planning LMS.

Take me to the eLearning
Use the Information

Our patients are relying on us to use the information about what is important to them, what their values and beliefs are, and what treatment and care they want . Not only to help make decisions when they can no longer make decisions for themselves but also to influence the way we communicate with them, the way we work with them and the way we support them from now until they cannot speak for themselves.

If you are unsure of the legal framework for decision-making, and how Advance Care Planning can change outcomes you will find the eLearning module useful.

An ambulance arriving at Emergency

considering your own future health care module

Advance Care Planning eLearning
Healthcare workers can now access the eLearning modules through the Advance Care Planning LMS.

Take me to the eLearning
Circumstances change

Patients have expressed concern that their plans may be ignored if they have not been updated recently. And in reality many clinicians reduce their reliance on previously stated preferences if some time has elapsed since they were recorded.

A newborn baby

Many people’s values and beliefs don’t change with the passing of time. However their care and treatment preferences and plans may well need to be revisited if circumstances change, for example if they:

  • have got married
  • had a baby
  • been diagnosed with a life-limiting illness
  • have declining health
  • are expecting their first grandchild and want to live to see that...

If patient-centric care planning is part of the way you work with your patients, their plan should already account for these changes.

If not, either:

  • set up a system to review the plans with your patients
  • ask another member of the health care team to take responsibility for reviewing the Advance Care Plan
  • ensure the person knows to review their Advance Care Plan themselves at regular review dates or if circumstances change