ACP in General Practice


Practice nurses will come into contact with many older patients in the practice for whom ACP could be useful.

Recommending ACP or ACDs to Older People

ACP could potentially benefit all older patients in your practice. However, ACP may specifically be relevant for:
  • The older person who indicates that they would like to talk about their future healthcare and medical treatment.
  • The older person with significant medical conditions.
  • The older person with a diagnosis of a new significant or terminal medical condition.
  • When an older person has a significant change in their medical condition, such as the need for home oxygen, significant deterioration, inability to perform daily activities or deterioration in measurement of function on tests results.
  • At key points in an older person’s illness trajectory, such as hospitalisation or after a life-threatening event.
  • As part of a specific older person healthcare assessment, such as the 75+ health assessment or if the older person requires / requests a comprehensive medical assessment.
  • When the answer is ‘No’ to 'The Surprise Question’ : ‘Would you be surprised if this person died within the next 12 months?".
  • When the older person is at risk of losing mental capacity in the next 12 months through diagnosis of early dementia or another progressive neurological disorder.
  • When there is a change in care needs such as the older person becoming a recipient of home care or has been admitted to a residential aged care facility.

A Practice Approach

Resources for Patients and Families

ACP Resources for General Practice Staff

Claiming MBS items for ACP

Helpful Resources



Page updated 23 May 2017


palliAGED is funded by the Australian Government Department of Health.