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Advance Care Planning

Talk to your patients

We are asking GPs to encourage their patients to start a conversation about their wishes for end of life care, or advance care planning. The document which captures these plans is called an 'Advance Care Directive'. 

To support general practice in initiating advance care planning conversations and assessing patient’s and carers palliative and supportive care needs, NBMPHN worked with HammondCare to deliver a number of workshops across the region.

The Advance Project offers a free, evidence-based training package and suite of resources. The Advance Project was specifically designed to support GPs, nurses and practice managers to work as a team to initiate conversations about advance care planning and to assess patients’ and carers’ palliative and supportive care needs. 

Advance Care Planning and Advance Care Directive

Advance Care Planning and Advance Care Directives are two aspects of end of life planning:

Advance Care Planning (ACP) is the process of developing future plans for a person's health and personal care that respects their values, beliefs and preferences. Advance care planning involves discussion with health professionals, family and friends, and could include a written advance care directive. 

Advance Care Directive (ACD) is a planning document written by a person with capacity that is authorised by common law or by legislation (laws vary across Australia). In NSW, advance care directives are recognised at common law. The NSW Guardianship Act 1987 provides substitute decision makers through the 'person responsible' hierarchy and allows appointed Enduring Guardians to consent to end of life decisions. 

An advance care directive can either:

  1. Record a person's values, life goals and preferred outcomes, or directions about medical treatment and care (an instructional directive); or
  2. Formally appoint a substitute decision maker (Enduring Guardian); or
  3. Do both of these things. 

The Department of Health National Framework for Advance Care Planning Documents.


A number of resources are available to assist you in starting a conversation about advance care planning and/or setting up an advance care directive for your patient.

  1. NSW Ambulance offers an Authorised Care Plan document that can be completed with your patient and a General Practitioner Information Kit about Authorised Palliative Care Plans.
  2. My Health Record - you can upload an Advance Care Directive document to your patient's My Health Record. Advance Care Planning documents can be uploaded to My Health Record by patients and can be viewed by their GP or other registered clinicians with permission.
  3. The RACP offers an Advance Care Planning position statement for general practice.
  4. Advanced Care Planning Australia provides information and resources to general practice staff on how to manage Advance Care Planning, along with guidance on the use of MBS items
  5. The NBM HealthPathways website offers Palliative Care pathways and information. 
  6. ELDAC (End of Life Directions for Aged Care) provide an evidence based Primary Care Toolkit to support palliative care and advance care planning. 
  7. Healthdirect Australia operates the NSW Palliative Care After-Hours Helpline (1800 548 225) which provides support to people who are receiving palliative care. It also assists health professionals, such as GPs, to support palliative care patients who choose to remain at home.
  8. Palliative Care Australia provides information for health professionals.

Community based end of life care previously provided under the ‘PEACH Program’ will now be coordinated and delivered by Primary Care and Community Health (PCCH) and the Supportive and Palliative Care Service. The End of Life and Palliative Care Coordinator is the single point of contact for end of life referrals and advice and can be contacted on 0456 953 341.

More Information

For more information, please call Janice Peterson on 4708 8100 or contact us online