Advance care planning information for clinicians

What matters most to consumers and their whānau should be at the centre of care planning and delivery.

These pages provide staff working in health care with the tools, training and support to develop the skills, confidence and systems to achieve this goal.

Evidence shows consumers and their whānau want open, honest communication from their health care team, but receive this to varying degrees. We can support consumers to make better treatment and care choices by including what is important to them, their values, preferences and goals into the decision-making process. Advance care planning is one way we can do that.

Order resources

We have a suite of advance care planning tools and resources to help people think about and document what matters most to them.

Digital PDFs of our advance care plans, guides and brochure are available here.

Clinicians can order My advance care plan & guide booklets here.

Small quantities of Whenua ki te whenua and Tōfā Fetāla’i advance care planning booklets can be ordered here.

About advance care planning

Advance care planning is the process of thinking about, talking about, and planning for future health care and treatment. Advance care planning is a person/whānau-led process and there are a number of different ways a person and their whānau might want to do this (for example, at a marae, with whānau, with their clinical team, alone or with other members of their community). It is important the health care team supports them in that process.

An overview of advance care planning in Aotearoa New Zealand

In New Zealand, advance care planning is a process. The focus is on understanding what is important now and in the future. This video gives an overview of the advance care planning process including the tools available to support this work.

Advance care planning is not just about end of life care and treatments

It is the process of empowering consumers to participate in their health care planning and deciding what treatment and care best meets their values, goals and preferences now and in the future.

An advance care plan captures what is important to the person and outlines the care and treatment they would want if unable to communicate for themselves. 

Shared goals of care discussions are a part of the advance care planning process. These discussions are with a person and/or their whānau about the goals of care for a specific admission to hospital, aged residential care or long term care facility.

The Serious Illness Conversation Guide Aotearoa supports clinicians to have conversations with seriously ill people and their whānau, including shared goals of care discussions.

Shared decision-making in health care is complex and when it does not go well it causes harm to consumers and their whānau. The video exploring how the way we work impacts consumer experience explores what consumers experience when shared decision-making does not go well and what clinicians think might contribute to it.

Benefits

Advance care planning, including shared goals of care, has benefits for the person and their whānau, health care staff and for the health care system.

What clinicians can do

1. Create your own advance care plan.

2. Prepare yourself to have conversations with consumers by:
– considering your biases
– ensuring you have the skills and confidence.

3. Have conversations with the person and their whānau.

4. Document the person’s goals, values, preferences and advance directives.

5. Use what matters most to the person and whānau in care planning and delivery.

6. Promote advance care planning:
– to the person and their whānau
– within your team or organisation

Related resources

My advance care plan

Saving your electronic ACPlan for record keeping and sharing

• Advance care plans, guides and brochures are available online here

• My advance care plan & guide booklets can be ordered here

• Download the five year strategy as PDF or Word doc

• Advance care planning 101 presentation and guidelines for use:

The presentation is designed to be delivered to health care staff who don’t have a great deal of knowledge about advance care planning. It can, and should, be adapted for the audience you are presenting to. If all the content is presented as it is, it will take approximately an hour. There are also guidelines about how to deliver the presentation. See documents below:
Advance care planning 101 presentation | Guidelines for using the advance care planning 101 presentation