Advance Care Planning Screening Interview

Notes for Interviewer

Suggested introduction
“As part of the seniors annual check up we ask everyone about their future health wishes. Are you OK to talk with me about this for 5 to 10 minutes?”

OR

“In the next 5 to 10 minutes, could I ask a few questions about your future health wishes?”
 
FOLLOWED BY: 
“Your answers will give me useful information about your needs and wishes and allow me to work out the best way to help you (with Advance Care Planning)”.

What is Advance Care Planning?
Advance care planning is a process that helps you to plan for future medical care. This process involves thinking about your values and beliefs and your wishes about the medical care you would like to have if you became critically ill or injured. It is a way to make sure that people involved in your life understand your wishes about medical treatment and care. You may choose to write down an Advance Care Directive that records your specific wishes in the event of serious illness, and any treatments you would refuse.

Instructions for use
The unshaded sections in the Tables on pages 2 to 3 are questions for the interviewer to ask the patient, and record the response. The shaded sections in the Tables on pages 2 to 3 are prompts for the interviewer, with some prompts also requiring a written response. On page 4 there is space to write any additional notes about the patient’s wishes or other topics that come up during the interview.

For further information about advance care planning, and substitute (or surrogate) decision making legislation and the appointment of formal legal medical enduring guardians (or equivalent) in your state please refer to: 
Advance Care Planning Australia
http://advancecareplanning.org.au 

RACGP Advance Care Planning 
http://www.racgp.org.au/your-practice/business/tools/support/acp  

Patient Name: <<Patient Demographics:Full Name>>
Date:<<Miscellaneous:Date>>	
1.	Have you ever thought about who you would like to make medical decisions for you in an emergency if you were too unwell to speak for yourself? If so, who?
a. Spouse
b. Family/friend carer
c. Relative
d. Friend
e. Not sure
f.  No-one identified	
Is this person’s name and contact details listed below or clearly recorded in the practice records
Preferred Substitute Decision Maker’s Name: __________________________
First contact number          ____________________________
Second contact number    ____________________________	Yes	No	N/A	
2.	Have you ever signed a legal document to appoint someone to make health decisions on your behalf if you were unable to?	Yes	No	
Note:
•	There are different terms for this in each state
•	This is different to appointing someone to make money or finance decisions	
If so, is a copy of the documentation available in the patient’s practice records?	Yes	No	N/A	
If so, is this person’s contact details listed above or in the practice records?	Yes	No	N/A	
If not, consider providing information about how to do this in your state, especially if the patient’s preferred substitute decision maker is someone who might not automatically be consulted according to the hierarchy in your state. See state specific information available at http://advancecareplanning.org.au  or  
http://www.racgp.org.au/your-practice/business/tools/support/acp/	
3.	Have you talked to anyone in your family or a close friend about your wishes, values and beliefs about medical treatment and care in case you become seriously ill or unable to make your own decisions?	Yes	No	
If yes, with whom?	
4.	Have you talked to a doctor about your wishes, values and beliefs about medical treatment and care in case you become seriously ill or unable to make your own decisions?	Yes	No	
If yes, with whom?	
5.	Have you ever written down your wishes, values and beliefs about medical treatment and care in case you become seriously ill or unable to make your own decisions?	Yes	No	
If so, in what type of document?	
If so, when was this last reviewed?	Date		
Where do you keep a copy?	
Is a copy available in the practice record?	Yes	No	N/A	

Patient Name:<<Patient Demographics:Full Name>>
Date:<<Miscellaneous:Date>>	
Is a copy available in your My Health Record?	Yes	No	N/A	
6.	Have you heard of Advance Care Planning or Advance Care Directives?	Yes	No 	
Explain to the patient about Advance Care Planning using the script on page 1 as necessary.	
7.	Would you like an information brochure about Advance Care Planning?	Yes	No 	
If so, has a copy of this been provided?	Yes	No	
8. Would you be comfortable if a member of the practice were to further discuss Advance Care Planning with you?
	Yes	No	
8i. If so, who would you like to discuss this with?
a.	GP
b.	General Practice Nurse
c.	Other ____________________________
	
8ii. If so would you like to discuss this with a family member, friend or someone who cares for you also present? If so with whom?
	Yes	No	
Record this person(s) name and relationship to the patient: 
______________________________________________________	
9.	Is there anything else you would like the practice to know about your wishes or priorities when it comes to your health care? 
(record details here or on the next page if more space is required) 

	Yes	No	
10.	Please rate your level of comfort with our conversation today.
a.	Very comfortable
b.	Somewhat comfortable
c.	Uncomfortable	
Was their preferred substitute decision maker present during the screening interview? 	Yes	No	
Was anyone else present?	Yes 	No	
If so, what was their relationship to the patient?	
Time taken to complete the interview (minutes)		
Completed by:<<Doctor:Name>>	Date: <<Miscellaneous:Date>>	

Patient Name: <<Patient Demographics:Full Name>>
Date: <<Miscellaneous:Date>>	
Notes about the patient’s wishes or other topics that come up during the interview:

Completed by: <<Doctor:Name>>  <<Doctor:Provider Number>>	
Date: <<Miscellaneous:Date>>