Key role of health, aged and disability care teams

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This article by Advance Care Planning Australia Program Director Xanthe Sansome first appeared in Australian Ageing Agenda and Community Care Review.

Choosing a career in health, disability or aged care is often motivated by a genuine love of people and a desire to provide optimal and individualised care. Knowing who a person is and how they want to be cared for are the central aspects of advance care planning (ACP). Supporting people with ACP is a privilege, and providing care in line with their preferences is even more so.

Unfortunately, the majority of Australians have not engaged in ACP and do not have an advance care directive. Health, aged, and disability care teams play a key role in ACP so it’s important to have a good understanding of what ACP is and what is involved in the process.

Advance care planning helps loved ones and health and aged care providers know and respect the person’s treatment and care preferences. It offers the best chance for everyone to live life on their own terms as they face more health challenges, and enables care provided towards their end of life to be in accordance with their unique preferences.

National Advance Care Planning Week

National Advance Care Planning Week from 20 – 26 March is an ideal time to learn more about ACP and make it part of your everyday work practice.

How can you assist in your role?

You can help provide opportunities for ACP in your service in several ways. You can:

  • Host an ACP Week event and get some free resources
  • Attend free education and learn how to start the conversation
  • Complete an audit of ACP within your service using the ACP Improvement Toolkit for your state/territory
  • Ask people if they have an advance care directive or have appointed a substitute decision-maker
  • Talk often about their health care and personal care preferences
  • Ask them why these things matter to them
  • Facilitate a discussion with the person, family members and doctors so all can be on the same page, especially if the person has reduced decision-making capacity
  • Share completed documents with other services involved in their care, such as hospitals
  • Incorporate the preferences expressed in documents or from discussions into the provision of high-quality care, especially end-of-life care. Many people you are caring for may have reduced decision-making capacity, which may change the way they undertake advance care planning.
  • If the person you are supporting has reduced decision-making capacity, involve them in the process as much as possible and detail their preferences in an advance care plan for a person with insufficient decision-making capacity.

Guide for aged care providers

Advance Care Planning Australia has produced Advance care planning in aged care: A guide to support implementation in community and residential setting, which offers comprehensive information on advance care planning, specific to the aged care sector. This includes engaging with people and their families, policies and procedures and legal aspects relevant to each state and territory.

Free resources and support

Access advance care planning documents for each state and territory, conversation starters, an Advance Care Planning Improvement Toolkit for workplaces and resources in 18 languages.

For free, personalised advice, to make a referral or request a printed starter pack, call the National Advance Care Planning Support Service on 1300 208 582 from 9am - 5pm (AEST/AEDT) Monday to Friday.


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