Advance Care Directive

How do I do an Advance Care Directive?

There are four (4) key steps you can take now:

Talk about your views and preferences with your family, doctor, carers and close friends Appoint an Enduring Power of Attorney (medical) who can make health care decisions on your behalf if needed. Write down your views and preferences for your family and doctors in a document called an ‘Advance Care Directive’

Give copies of your Advance Care Directive to your family, doctor and hospital staff on admission

If you still need further information, staff will be available to discuss and Advance Care Directive with you during your admission, if you wish to take the Advance Care Directive

Form home please discuss this with the staff.

What is a Substitute Decision Maker / Power of Attorney?

A Substitute Decision Maker/Power of Attorney is a legal document where you can nominate a person to manage your medical or financial decisions.

It is advised that this is completed before any acute medical illness or condition occurs It may not be possible for this document to be attended to once you become unwell.

You can get the forms to fill out an Enduring Power of Attorney from the Office of the Public Advocate website.

You can also speak with nursing staff or your medical officer for more information.

Website: www.publicadvocate.vic.gov.au

Telephone: 1300 309 337

Goals of Care

Goals of care describe what a patient wants to achieve during an episode of care, within the context of their clinical situation Goals of care are the clinical and personal goals for that patient’s episode of care that are determined through a shared decision-making process

Identify goals of care when the patient is admitted

The treating team works with the patient and family to identify goals of care

Goals of care inform medical decision-making and limitations of medical treatment (resuscitation plan)

Medical management aligns with the patient’s values and preferences from the point of admission.

Revisit goals of care when:

The patient is re-admitted to hospital

There are significant changes in the patient’s condition or circumstances

The patient, substitute decision maker or family request it

The patient, substitute decision maker or family expresses concerns

About goals of care

Active medical treatments and end of life care are not mutually exclusive Goals of care are reflected in the clinical treatment plan, limitations of medical treatment (resuscitation plan) and advance care planning.

Goals of care guide treatment at times of crisis

Crisis’ often occur after hours. Without documented goals of care, clinicians who don’t know the patient are forced to make decisions in the heat of the moment and without the input of the patient or substitute decision maker.

Who may be involved in your care

During your admission there may be several staff who will care for you, this may include:

Nursing staff

Your doctor or the doctor providing after hours coverage

Allied health professionals

Nursing visits

Each visit the nursing staff will check your vital signs (blood pressure, pulse, temperature, breaths, oxygen saturation and pain levels)

They will also complete a care plan. This will include them questioning you about if you are managing with activities of daily life, for example toileting, preparing and eating meals and hygiene.

Nurses will also complete the required care for the visit and complete paperwork to ensure an accurate record of your health journey.

Doctors’ visits

While you are on the NCN@HomeHITH program a doctor will be managing your care.

You will need to have a doctor’s visit to determine your initial and ongoing needs, to order investigations and medications.

Further doctors’ visits may be required to assess if the current care is appropriate and to make changes as required.

Telehealth visits can be arranged if these suit both the doctor and patient.

Allied Health Professionals

If, during a nursing or medical visit a need for an allied health professional (physiotherapist, occupational therapist, exercise physiologist, dietitian, social worker, diabetes educator, chronic disease worker) is recognised a referral can be completed.

It is our aim to have an appointment set up prior to the program ending.

In some situations, a telehealth appointment may be arranged for you ensuring you have access to appropriate and timely care.