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By ISQua Wednesday. Sep 7, 2016

Advance Care Planning (ACP) and its relevance to ISQua

guide decision-making at a future time when that person cannot make or communicate his or her decisions.”[i] 

Specifically ACP assists people to consider, discuss and document:

a)    their choice of substitute decision maker (SDM) should they become incapable of making decisions about their healthcare and/or

b)    their goals, values and preferences regarding future healthcare, including what would be an unacceptable outcome, and/or

c)    specific treatments (if any) that they would not want. 


Why is ACP important?

Given that all people die, the processes surrounding dying deserve the same quality improvement considerations as other aspects of healthcare. The majority of dying patients lose capacity to make or communicate decisions regarding their end-of-life healthcare and many receive treatment that they would not have chosen.


There is evidence that ACP improves:[ii],[iii],[iv],[v],[vi]

  • patient care, including end-of-life care
  • the likelihood of a person’s end-of-life wishes being known and respected by doctors and families
  • patient & family satisfaction with care
  • families’ perceptions of quality of death
  • the likelihood of a person dying in their preferred place
  • family preparedness for what to expect during the dying process.


There is also evidence that ACP reduces:2,3,4 ,[vii],[viii],[ix]

  • likelihood of unwanted treatment at end of life
  • the number of hospital admissions of people who would have preferred to stay at their home/RACF
  • stress, anxiety and depression in surviving relatives
  • distress amongst healthcare providers
  • ineffective or unwanted costly care at end-of-life without increasing mortality


ACP is also valuable for people whose illness, such as dementia or a stroke, has impaired their capacity to make health decisions but from which they are not about to die.


As described by Scott et al in the Medical Journal of Australia in 2013[x]“For ACP to become part of mainstream patient-centred care, accountable clinicians working in primary care, hospitals and nursing homes must effectively educate colleagues and patients about the purpose and mechanics of ACP, mandate ACP for all eligible patients, document ACP in accessible formats that enable patient wishes to accurately guide clinical management, devise methods for reviewing ACP decisions when clinically appropriate, and evaluate congruence between expressed patient wishes and actual care received.” We interpret “mandate ACP for all eligible patients” to mean that ACP should be raised with and/or offered to all indicated patients for whom it may be beneficial, whilst respecting the patient’s choice as to whether or not, and to what extent, they wish to consider, discuss and/or document ACP.


The principles of ACP align to the vision of ISQua- “to be the leader of transformation in healthcare quality and safety globally”. ISQua aspires to be person centered and less acute care centric. As the implementation of ACP in healthcare has evolved over time, there is greater recognition that ACP needs to begin in primary care, while the patient is well enough to participate. This will be discussed further in future articles; if you have any questions or would like any further information, please dont hesitate to contact me - This email address is being protected from spambots. You need JavaScript enabled to view it..


Assoc Prof William Silvester

Immediate Past President

International Society of Advance Care Planning and End-of-Life Care

Former and founding Director of Respecting Patient Choices, Melbourne

Hon Assoc Professor, University of Melbourne

Hon Assoc Professor, University of Sydney

Intensive Care Specialist

[i] Australian Health Ministers Advisory Council (AHMAC) (2011). The Clinical, Technical and Ethical Principal Committee. A national framework for advance care directives. Canberra


[ii] Detering KM, Silvester W, Corke C, Milnes S, et al. (2014). Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme.BMJ Supportive & Palliative Care: bmjspcare-2013-000450


[iii] Detering KM, Hancock AD, Reade MC, Silvester W. (2010). The impact of advance care planning on end of life care in elderly patients: randomised controlled trial.BMJ 340: c1345


[iv] Molloy DW, Russo R, Pedlar D, Bédard M. (2000) Implementation of advance directives among community-dwelling veterans.Gerontologist. 40(2); 213-217


[v] Teno JM, Gruneir A, Schwartz BA, Nanda A, Wetle T. (2007) Association between advance directives and quality of end-of-life care: a national study. J Am Geriatr Soc, 55(2); 189-194


[vi] The Gold Standards Framework. (Accessed August 2016)


[vii] Wright AA, Zhang B, Ray A, Mack JW, et al. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment.JAMA 300(14); 1665-1673


[viii] Elpern EH, Covert B, Kleinpell R. (2005) Moral distress of staff nurses in a medical intensive. American Journal of Critical Care. 14(6); 523-30


[ix] Zhang B, Wright AA, Huskamp HA, Nilsson ME, et al. (2009) Health care costs in the last week of life: associations with end-of-life conversations. Archives of internal medicine. 169(5); 480-488


[x] Scott IA, Mitchell GK, Reymond EJ, Daly MP. (2013). Difficult but necessary conversations--the case for advance care planning. Medical Journal of Australia 199(10): 662-666.


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