Palliative care

Advance Care Planning

  • Advance Care Planning 

    Advance care planning is a process of reflection, discussion and communication that enables a person to plan for their future medical treatment and other care. Advance care planning involves learning about the types of decisions that might need to be made, considering those decisions ahead of time, and then documenting preferences.

    The Goals of Patient Care Summary (GOPCS) is a 6 page advance care planning tool, intended to guide discussions and decision making for paediatric patients with life limiting conditions. Each page has a guide/doctor information component and a separate printable document for recording discussions, which can then be scanned into ESMR.

    The GOPCS incorporates medical, psychological, spiritual, religious and social domains related to patient care before, during and after death. In adopting a bio-psychosocial approach to advance care planning, it aims to facilitate difficult discussions with patients / families and health care professionals, and help guide decision-making in a sensitive, patient-focused model of care.

    The GOPCS is a living document where each page can be printed and completed separately over a number of meetings between doctors, nurses, allied health staff, patient and family. It is not necessary to complete all sections of the GOPCS, and patients/families may decide not to discuss certain aspects of the plan. Each page has a box to indicate date of completion, including who has been involved in the discussion (professional and child/parent/carer). As the goals of patient care are likely to evolve over time, individual sections may be updated by re-printing and completing the relevant page from the website link. Once updated, the relevant page of the plan should be scanned onto ESMR.

    While the GOPCS is designed to facilitate discussion and advance care planning in partnership with patients and families, it is important to note that the patient / guardian are not required to sign the document in order for it to be deemed valid.

    For doctors wishing for more guidance in an approach to the advance care planning discussion, some helpful guidelines and linked documents are included in a separate link below.

    Goals of patient care summary

    General patient information

     Diagnosis & background summary, key professionals involved and sibling details which may be relevant for completion on death certificate

      General Information Document: Page 1

      Information Guide: General Information

    Summary Treatment Plan

    Overview of goals of patient care, and outlines limitations (if any) of medical interventions. This page is to be completed by senior medical staff only, and may be particularly helpful in the event of an acute potentially life-threatening deterioration

    Summary treatment plan document: Page 2

    Information Guide: Summary treatment plan

    Key discussions & decisions

    A quick reference to key discussions and decisions made over time. e.g. significant changes in clinical condition including complex hospital admissions with ICU involvement, investigations or discussions with healthcare professionals where new information has come to light that may affect decision-making

    Key discussions document: Page 3

    Information guide: Key discussions & decisions

    Wishes during life

     This includes understanding of patient/family hopes, expectations, social supports, religious and spiritual values.

    Wishes during life document: Page 4

    Information guide: Wishes during life

    Plans as child deteriorates

    Expected disease trajectory and likely scenarios that may arise for this patient. Having this discussion allows an opportunity for patients / families to understand what may happen, and make choices about future care as they deteriorate and subsequently during end-of-life care

    Plans as child deteriorates document: Page 5

    Information Guide: Plans as child deteriorates

    Wishes for after death

    Funeral preferences, spiritual and cultural wishes and consideration for tissue/organ donation. This provides patients the opportunity to express their own wishes for when they die, and also allows family to make these arrangements ahead of time if they wish. There is a checklist included on this page which should be reviewed each time the GOPCS is discussed and modified.

    Wishes for after death document: Page 6

    Information Guide: Wishes for after death

    Triggers for advance care planning

    List of suggested triggers