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
Practice nurses have many opportunities to enhance ACP activities within their practice.
- They could raise the issue of ACP in practice meeting. The practice could consider different options such as holding ACP information in the practice and providing ACP leaflets to patients.
- ACP checks could be included in 75+ assessments.
- The practice could undertake an audit of patients to identify who could benefit from ACP conversations.
- Nurses can book long appointments with the GP where an ACP conversation could be important.
- Practice nurses can check if patients with an ACP would like to make a copy available to the practice.
- Nurses can let their patients know they can upload their ACP documents to their MyHealth Record.
- Practice nurses can make practice staff aware of MBS items that may be used by GPs for Advance Care Planning (ACP) (182kb pdf) where clinically appropriate.
- If a patient’s condition or circumstances change, the Practice nurse can prompt the patient to consider whether they need to update their ACP.
- If a nurse suspects cognitive changes, a conversation about ACP is important.
Resources for Patients and Families
Practices can order pamphlets and booklets on ACP and ACDs for their patients and their families through their state or territory primary healthcare networks or health departments. There are also websites that can assist with information on ACPs and ACDs:
ACP Resources for General Practice Staff
Claiming MBS items for ACP
MBS Item numbers may be used by GPs for ACP when clinically appropriate, e.g. existing terminal illness or chronic disease with potential to impact on duration and/or quality of life, or when it is requested by the patient.
MBS Items 701, 703, 705, 707 and 715 (Health Assessments) must be provided by a GP personally attending upon a patient.
Suitably qualified health professionals, such as practice nurses, Aboriginal and Torres Strait Islander health practitioners, and Aboriginal health workers, may assist the GP in performing Health Assessments.
Such assistance must be provided in accordance with accepted medical practice and under the supervision of the GP. This assistance may include activities associated with: information collection and providing patients with information about recommended interventions.
Detailed information on claiming MBS items for ACP in General Practice can be found in the following document:
ACP in General Practice - Guidance for MBS Items (182kb pdf).
The
National Advance Care Planning Support Service can also provide advice on ACP issues in general practice.
Helpful Resources
Page updated 16 December 2024