Advance care planning – Creating sustainable change in community palliative care

Mercy Palliative Care, a community palliative care service in western metropolitan Melbourne has been involved in a Latrobe University project to instigate the implementation of a manual for Advance Care Planning for community palliative care organisations.

Mercy Palliative Care recognises that patients should have Advance Care Plans prior to admission to a palliative care service, It also recognises that as a service these discussions are part of a process and may commence or continue with palliative care staff. This project has involved the review of documentation of discussions and the development of an education program to assist staff in recognising the discussion and documenting the outcomes appropriately.

A multidisciplinary committee was formed and Advance Care Planning in the context of community palliative care was defined. It was decided that patients creating an Advance Care Plan would be directed to their GP or medical specialist. Timely review of the patient information book resulted in Advance Care Planning information being included. In addition the new Allied Health assessment and care plan includes alerts for documentation of Advance Care Planning discussions. Community promotion of Advance Care Planning has included information in the organisational newsletter distributed to current patients and families, memorial donors and donors.

The inclusion of Advance Care Planning has been a process which will result in sustainable changes in procedures and policies and practice. This presentation will assist community palliative care organisations in developing a model of advance care planning that is practical and sustainable.