Advance Care Planning (ACP)

Advance Care Planning (ACP) is the process of thinking , talking and planning for future health care which includes end-of-life care. It is about identifying what matters to you. Best practice is to document your wishes about the type of health care and treatment you want to receive in the future. This information is especially important when you are not able to make your own decisions or towards the end of your life It's a good idea to think about ACP now, before you become seriously ill or injured. It's especially important to think about and discuss ACP if you have a terminal condition, are very frail, or have strong opinions about how and where you are treated at the end of your life.

A person creates an Advance Care Plan while they are still able to decide what they want in the future. An Advance Care Plan is done with the help of a health professional. This could be your GP, practice nurse, district nurse, medical social worker, cardiac, diabetes or respiratory specialist nurse, cancer nurse, hospice nurse or doctor.

My Advance Care Plan

You may wish to complete an Advance Care Plan (ACPlan) to document your preferences and wishes for healthcare at the end of your life. An ACPlan should be completed with the help of a health professional and be the result of your thoughts and discussions with your family/whānau and loved ones.

A health professional can explain to you the details of medical treatments for the very ill or injured and talk you through the benefits and risks of these treatments. If you wish, they can lodge your ACPlan on your electronic health record, to be shared with other clinicians and your GP if and when it's needed (for example, if you are seriously injured or unwell and in hospital).

It's very important that if you document an ACPlan, you give copies to your family/whānau, loved ones, Enduring Power of Attorney (EPOA) and/or those people whom you trust to advocate for you should you be unable to speak for yourself You should also keep a copy somewhere and inform those who live with you where to access it. It can be a good idea to file it along with your EPOA document, will and other important documents.

IMPORTANT - Your Advance Care Plan will support you and your healthcare team to plan and deliver care that supports what matters most to you. If you are ever unable to speak for yourself, what you have captured in your ACPlan will be used to inform what care and treatments are most appropriate for you.

Next steps

If you are thinking about ACP, you should take the following actions:

Read My advance care plan and guide.
Spend some time thinking about what values and beliefs around end-of-life issues are important to you and consider discussing this with your family/whanau and loved ones. Specific issues to consider include:

Do you have a strong preference about where you die?
Do you have any specific religious beliefs or spiritual issues?
What concerns or fears do you have regarding the end of your life?
Do you wish for your organs and/or tissues to be donated, if possible, when you die?

The ACP guide is there to support you to think through and write down your thoughts and ideas
If you wish to document your ACPlan and have this attached to your medical record at the hospital and with your GP, then you will require to use the Summary of my Advance Care Plan (PDF 167 KB) form.
Print the Summary of my Advance Care Plan document and read through thoroughly.
Fill out the Summary of my Advance Care Plan form (see below: Filling out my Advance Care Plan).
Make an appointment to discuss ACP with your chosen health professional.

IMPORTANT
If you are making an appointment with your GP and/or practice nurse, let them know in advance that your appointment is for an ACP discussion. This will help to ensure that the appointment is long enough. It will also give your GP and/or practice nurse the chance to prepare before you arrive. Your ACP discussion with your GP and/or practice nurse might require more than one appointment. You may wish to consider making a will and appointing an Enduring Power of Attorney (EPoA).

Remember, your ACPlan is a living document and can be changed/updated at any time.

Filling out my Advance Care Plan

A Taranaki-specific Summary of my Advance Care Plan (PDF 167 KB) form has been developed. Feel free to print this form and complete it. Ideally use a black pen, this ensures it is clearer when copies are made.

You should complete pages one and two with your family/whānau, friend or EPoA. Pages three and four of the plan needs to be completed with the help of a health professional because they have to sign that you are competent to make these decisions. Competency is a legal term meaning that you can fully understand the decisions you are making. If you don’t get a health professional to sign the form, other doctors might question your ability to make these decisions.

Question 1 (Page 1): Asks for your NHI number. You may not know this number which is fine. Just ensure that your full name, date of birth and address is clearly written and correct.

Question 8 (Page 3): Here you can choose only one option. If none of the first four options apply to you and your wishes, choose the last option - option five. If you choose option five you will need to complete an advance directive with a health professional to help you write down your wishes in a way that others will understand when you can’t speak for yourself. The New Zealand Medical Association has templates for you to use. An advance directive is not easy to complete and may need more than one appointment to discuss.

I've finished my Advance Care Plan - now what?

Make sure you have signed your 'Summary of my Advance Care Plan' document on page four.

Your health professional will also need to sign the document and then email a copy of your ACP Plan to acp.admin@tdhb.org.nz where it will be uploaded to your electronic file.

It is important to retain the original copy yourself and consider giving copies to your EPoA, lawyer, family/whānau, friend or neighbour. You can even keep a copy in your fridge in a life tube (available from your local Age Concern Taranaki. Phone 06 759 9196 or email info@ageconcerntaranaki.org.nz).

Keep a record of who has copies, so that if you require to update your ACPlan you can contact these people with any changes you wish to make.

Your health professional will need to email a copy of your ACP Plan to acp.admin@tdhb.org.nz where it will be uploaded to your electronic file.

Making changes to your Advance Care Plan

If you wish to alter your 'Summary of my Advance Care Plan' document, you can simply print off another copy and complete the process above again. Be sure to destroy any old plans and ensure all copies with lawyers, family / whānau or friends are changed also.

Further information

You can visit Health Quality & Safety Commission | ACP information for consumers (hqsc.govt.nz) for further information.

Contact us:

For all ACP queries in Taranaki, contact Te Whatu Ora Taranaki ACP facilitator:
Email: acp.admin@tdhb.org.nz
Phone: (06) 753 6139 (extension 7083)

Last updated: Thursday, May 11, 2023