General Practitioners & GP Practice Nurses

GPs and practice nurses

GPs often have a long-term relationship with their patients, including those with serious chronic disease and life-limiting illness such as Alzheimer’s disease and other forms of dementia. As a GP, you can play a vital role in helping your patients to understand their medical condition and to plan for the future, including possible choices they may have to make about their future healthcare.

Advance care planning

The Royal Australian College of General Practice (RACGP) believes that advance care planning should be incorporated into routine general practice and it has published a Position Statement on the issue.

“ACP is a process of reflection, discussion and communication that enables a person to plan for their future medical treatment and other care, for a time when they are not competent to make, or communicate, decisions for themselves.

ACP is about person-centred care and is based on fundamental principles of self-determination, dignity and the avoidance of suffering.

Advance care planning will often involve the following components:

  • Discussions about prognosis and possible future scenarios and patient concerns
  • Appointment of a Substitute Decision Maker(s) and their involvement in initial and subsequent ongoing documented discussions
  • Reaching consensus on current and possible future ‘goals of care’. These goals may be supported by a statement describing the reasoning underpinning the choices a patient has made
  • Discussing choices around preferred place of care during their illness and in the ‘terminal phase’
  • Documenting these discussions in an easily retrievable format, held by the patient, their substitute decision-maker, their family and GP.
  • If appropriate encourage patients to complete power of attorney documents and wills

All of the above components can be strengthened if the patient’s primary carers and family are involved in some way.”

RACGP Position Statement: advance care planning should be incorporated into routine general practice

How to incorporate ACP into patient care

GPs may be hesitant to discuss advance care planning. But one way to raise the subject is to introduce a simple approach to advance care planning into the general routines of patient management. Part of this approach may be to use practice nurses to allocate time with patients to help them go through an advance care planning process. Another aspect is to routinely include advance care planning in all Over-75 Health Checks and all Comprehensive Medical Assessments done in aged care facilities. 

What you can do

  • Screen patients who are at trigger points where planning ahead and advance care planning are particularly relevant. These include:
    • memory problems or signs of early dementia
    • progression and worsening of a chronic disease
    • diagnosis of a life limiting illness, or
    • increasing dependence on others for support and care.
  • Arrange training for practice nurses in advance care planning
  • Find out if there are advance care planning programs in your local area and give the person resources from this program.
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  • Allocate time to follow up with any patient who wants to explore the issues further or else make arrangements for them to see a local service where available or another staff member of the practice where appropriate.
  • Include questions about advance care planning in all Over-75 Health Checks.
  • If you have patients in aged care facilities, discuss with the staff how you can help build advance care planning into the overall model of care provided.

Give the person these three leaflets about Early planning and Start2Talk and Who will speak for you if you can't? and offer to help them if they want to explore the issues further.

Resources for GP's and GP practice nurses