Improving Patient Outcomes Through Accessible Advance Care Plans

Imagine a scenario where, in the midst of a medical emergency, a patient’s advance care plan is nowhere to be found because it's tucked away in a GP’s paper file or at home with family. This frustrating reality highlights a critical gap in healthcare — the limited accessibility of advance directives when they are needed most. This post explores why making these documents digitally accessible is more than a convenience; it is a necessity for ethical, effective patient-centred care.

The Accessibility Problem: When Advance Directives Are Out of Reach

Advance care planning (ACP) is a cornerstone of ethical, patient-centred care. However, a significant barrier persists: limited accessibility of advance directives when they are needed most. Despite best intentions, many ACP documents remain physically locked away—filed at a general practitioner’s clinic, stored in a home drawer, or lost in a sea of paperwork. In the context of medical emergencies, where timely decisions are critical, this lack of accessibility can have profound consequences for patients, families, and clinicians alike.

Advance Care Plans: Present but Inaccessible

The reality in many healthcare settings is that advance care plans often exist but are not available at the point of care. When a patient presents to hospital in a crisis, the treating team frequently cannot access their documented wishes. Studies have shown that nearly 70% of advance directives are inaccessible during emergencies, leaving clinicians without the guidance needed to deliver care aligned with patient values. In some UK hospitals, only 5% of acute care admissions had an accessible ACP on record. This disconnect between planning and practice undermines the very purpose of advance care planning.

Clinical and Ethical Implications of Limited Accessibility

The consequences of inaccessible ACPs extend beyond administrative inconvenience. When advance directives are out of reach, patients are at risk of receiving non-beneficial or unwanted treatments that may not reflect their preferences or values. This not only compromises the quality of care but also raises significant ethical challenges for clinicians, who may be forced to make decisions in the absence of clear patient direction. The lack of accessible ACPs can also result in:

• Increased family distress: Families may struggle to communicate a loved one’s wishes, especially under the stress of a medical emergency.
• Clinician uncertainty: Without clear documentation, healthcare providers may feel uncertain or conflicted about the most appropriate course of action.
• Reduced satisfaction with care: Both patients and families are less likely to feel that care was person-centred when advance directives are not followed.

“We knew what Mum wanted, but her advance care plan was at her GP’s office. In the emergency, we couldn’t get it in time. The doctors did everything, but it wasn’t what she wanted.”
— Daughter of a patient, recounting a recent hospital admission

Plan ahead with confidence — create your free Advance Care Plan in the Evaheld Legacy Vault to record your healthcare wishes, appoint decision-makers, and give your loved ones clarity, comfort, and peace of mind.

Emerging Standards: Digital Accessibility as Best Practice

Healthcare systems are increasingly recognising that digital accessibility of advance care planning is not just a convenience, but a clinical and ethical imperative. The emerging standard of care expects that ACPs are readily available to authorised clinicians across care settings, especially during medical emergencies. This shift is essential for reducing unwanted interventions, supporting ethical decision-making, and improving family satisfaction with care.

Bridging the Gap: The Evaheld Ecosystem

The Evaheld ecosystem addresses this critical gap by serving as the interoperability layer between community and acute care. Within Evaheld, a patient’s Legacy Vault securely stores their advance care plan. With patient consent, healthcare providers can be granted secure, time-limited access to view the ACP via a share function. This approach ensures that advance directives are accessible when and where they are needed, supporting truly patient-centred care and upholding the highest standards of clinical governance.

Ultimately, making advance care planning easily accessible is central to delivering ethical, high-quality, and person-centred care—especially in the moments that matter most.

Connecting Accessible ACPs with Clinical and Ethical Outcomes

Advance Care Planning (ACP) is a cornerstone of ethical, patient-centred healthcare. However, the clinical impact of ACPs is often undermined by poor accessibility. Too frequently, even when a patient has thoughtfully completed an advance directive, it remains out of reach—buried in a GP’s paper file or at home—rendering it useless in critical hospital situations. This disconnect between the existence of an ACP and its availability at the point of care is a significant barrier to achieving best-practice clinical governance and ethical decision-making.

Accessible ACPs: Reducing Non-Beneficial and Unwanted Treatments

Accessible ACPs directly support the reduction of non-beneficial or unwanted treatments. When clinicians can quickly access a patient’s advance directive, they are empowered to align interventions with the patient’s clearly expressed wishes. This not only prevents unnecessary procedures but also reduces the risk of causing distress or harm through treatments that the patient would not have wanted. Evidence shows that accessible ACPs significantly improve concordance between patient preferences and the care actually delivered, leading to better clinical outcomes and resource utilisation.

Improving Family Satisfaction by Honouring Patient Preferences

Family satisfaction is closely tied to the healthcare team’s ability to honour the patient’s treatment preferences. In the absence of accessible ACPs, families may be left uncertain or distressed, especially during acute or end-of-life situations. By ensuring that advance directives are readily available, clinicians can provide care that is consistent with the patient’s values, reducing family anxiety and conflict. Studies consistently report that families experience greater satisfaction and less decisional regret when they see their loved one’s wishes respected.

Supporting Ethical Decision-Making in Complex Care

Accessible ACPs are essential for ethical decision-making, particularly in complex or high-pressure clinical scenarios. When clinicians have timely access to a patient’s documented preferences, they are better equipped to make decisions that respect autonomy and dignity. This transparency supports shared decision-making, fosters trust, and ensures that care is guided by ethical principles rather than assumptions or default protocols. The presence of an accessible advance directive also clarifies the role of surrogate decision-makers, reducing ambiguity and potential conflict.

Enabling Clear Communication and Compliance

Clear communication regarding goals of care and surrogate decision-makers is a critical component of quality improvement and clinical governance. Accessible ACPs enable all members of the care team to understand and act upon the patient’s wishes, ensuring consistency across settings and providers. This not only enhances compliance with legal and ethical standards but also supports accreditation and risk management efforts within healthcare organisations.

Anecdote: Digital ACP Access in a Critical Hospital Case

Consider the case of an elderly patient presenting to the emergency department with advanced dementia and respiratory failure. The family was distressed, unsure of the patient’s wishes, and unable to locate the paper advance directive. However, through the Evaheld ecosystem, the patient’s Legacy Vault provided secure, immediate access to her ACP. With her documented preferences available, the clinical team avoided invasive interventions, provided comfort-focused care, and supported the family through a difficult decision. This scenario highlights how digital ACP access transforms care delivery, making ethical, patient-centred care a practical reality.

The Evaheld Ecosystem: Bridging Community and Acute Care

The emerging standard of care now expects digitally accessible ACPs as a best-practice requirement. The Evaheld platform serves as the critical interoperability layer, allowing patients to store their advance directives in a secure Legacy Vault and grant healthcare providers time-limited, consent-based access. This bridges the gap between community and acute care, ensuring that ethical decision-making, family satisfaction, and clinical governance are not compromised by information silos.

The Emerging Standard: Digital Advance Care Plans as Best Practice

Despite the growing recognition of advance care planning (ACP) as a cornerstone of ethical and person-centred healthcare, a persistent problem remains: even when a patient has thoughtfully completed an advance care plan, it is often inaccessible at the critical moment. Paper-based ACPs are frequently left at home or filed away in a general practice clinic, rendering them invisible to clinicians during hospital admissions or emergencies. This gap undermines the intent of ACPs and can lead to non-beneficial interventions, increased family distress, and ethical dilemmas for healthcare teams.

Digital Advance Care Plans: A Clinical Governance Imperative

Clinical governance frameworks increasingly recognise that digital advance care plans are not just a technological upgrade, but a fundamental requirement for high-quality, patient-centred care. Accessible ACPs directly support key clinical goals:

• Reducing non-beneficial or unwanted treatments: When clinicians can instantly access a patient’s documented wishes, care aligns with the person’s values, reducing unnecessary interventions and hospital stays.
• Improving family satisfaction: Families are reassured when care teams respect and follow the patient’s preferences, minimising conflict and emotional burden during critical decisions.
• Supporting ethical decision-making: Ready access to ACPs provides clinicians with clear, patient-endorsed guidance, reducing moral distress and supporting best-practice care.

Healthcare Interoperability: Bridging Community and Acute Care

Healthcare systems worldwide are moving towards interoperability of ACP records, recognising that seamless information flow is essential for continuity of care. Interoperability ensures that a patient’s ACP, regardless of where it was created, is available to authorised clinicians across all care settings—community, hospital, and beyond. This approach is rapidly becoming a best-practice expectation in clinical governance, with regulatory bodies and accreditation standards increasingly encouraging or mandating digital ACP integration.

Evaheld’s Legacy Vault: A Practical Interoperability Solution

The Evaheld ecosystem exemplifies how technology can bridge the longstanding gap between community and acute care. At the heart of Evaheld is the Legacy Vault, a secure digital repository where patients can store their ACP and other vital documents. With patient consent, healthcare providers are granted secure, time-limited access to view the ACP via a simple share function. This model ensures:

• Real-time access: Clinicians can view the most current ACP instantly, supporting timely and informed decision-making.
• Patient control: Patients retain ownership of their information, deciding who can access their ACP and for how long.
• Information security: Evaheld meets rigorous privacy and security standards, ensuring sensitive data is protected at all times.

Ethical Access Through Patient Consent

A core principle of facilitated ACP services is that patient autonomy and privacy are paramount. Digital platforms like Evaheld employ robust consent mechanisms, allowing patients to authorise access only when and to whom they choose. This approach upholds ethical standards while enabling clinicians to deliver care that truly reflects the patient’s wishes.

Future Outlook: Seamless Integration and Quality Improvement

The future of advance care planning lies in the seamless integration of digital ACPs into electronic health records and clinical workflows. As regulatory frameworks evolve and technology advances, digital ACPs will become embedded in routine care, further enhancing healthcare quality, safety, and person-centredness. The shift towards interoperable, secure, and patient-controlled ACPs is not just a technological trend—it is the emerging standard for ethical and clinically excellent care.

Evaheld's Legacy Vault: Bridging Gaps in Patient-Centred Care

Advance care planning (ACP) is a cornerstone of ethical, clinically excellent, and truly patient-centred care. Yet, a persistent challenge remains: even when patients have thoughtfully completed an advance care plan, these documents are often inaccessible at the critical moment. ACPs are frequently stored in paper files at a general practice or left at home, rendering them effectively invisible to clinicians during hospital admissions or emergencies. This gap in accessibility undermines the very purpose of ACPs, leading to non-beneficial interventions, family distress, and ethical dilemmas for healthcare teams.

Evaheld Legacy Vault: The Interoperability Layer for Secure ACP Access

The Evaheld Legacy Vault addresses this challenge by acting as a secure, patient-controlled digital repository for advance care plans and directives. As an interoperability layer, Evaheld bridges the divide between community and acute care settings, ensuring that ACPs are not only stored safely but are also accessible when and where they are needed most. Patients upload their ACPs to their personal Legacy Vault, maintaining full control over who can access their sensitive information.

• Patient empowerment: Individuals decide who can view their ACP, granting access only to trusted healthcare providers.
• Privacy safeguards: Access is both secure and time-limited, with robust consent mechanisms built into the platform.

Transforming Clinical Outcomes Through Advance Care Plan Accessibility

Accessible ACPs are directly linked to improved clinical outcomes and ethical care delivery. When clinicians can quickly access a patient’s advance directives via the Evaheld Legacy Vault, several key benefits emerge:

• Reduction in non-beneficial treatments: Ready access to ACPs allows clinicians to align interventions with the patient’s documented wishes, avoiding unnecessary or unwanted procedures.
• Enhanced family satisfaction: Families experience greater peace of mind knowing that their loved one’s preferences are respected, reducing conflict and distress during critical moments.
• Support for ethical decision-making: Clinicians are empowered to make decisions that honour patient autonomy, supported by clear, accessible documentation.

Meeting the Emerging Standard of Care

Digital accessibility of ACPs is rapidly becoming a best-practice expectation within the healthcare sector. Clinical governance managers, directors of nursing, and medical executives are recognising that paper-based systems are no longer sufficient. The Evaheld Legacy Vault exemplifies this new standard, providing a real-world solution that integrates seamlessly with existing clinical workflows.

“Patient-controlled digital vaults, like Evaheld’s Legacy Vault, are enhancing the ethical delivery of care by ensuring that advance care plans are always available to guide decision-making.”

Practical Application: Secure ACP Access in Action

Consider the scenario of a patient presenting to the emergency department with a sudden, life-threatening event. Through Evaheld’s innovative share function, the treating clinician can—with the patient’s prior consent—securely access the ACP stored in the Legacy Vault. This time-limited, audit-trailed access ensures that the patient’s wishes are immediately available, guiding care decisions in real time. The result is a seamless bridge between community-held preferences and acute care delivery, supporting both patient-centred care and clinical excellence.

By facilitating secure, consent-based ACP access, the Evaheld Legacy Vault is setting a new benchmark for interoperability and patient empowerment. It ensures that advance directives are not just completed, but are actionable—whenever and wherever they are needed most.

Overcoming Healthcare System Barriers to ACP Accessibility

Advance Care Planning (ACP) is a cornerstone of ethical, person-centred, and clinically excellent care. Yet, despite its recognised value, significant healthcare system barriers continue to limit the accessibility and utility of ACP documents when they are needed most. For clinical governance managers, directors of nursing, and medical executives, addressing these barriers is essential for quality improvement and upholding best practice standards.

Systemic Obstacles to ACP Accessibility

One of the most persistent barriers is the reliance on paper-based records. Even when a patient has thoughtfully completed an ACP, it is often stored in a GP’s office or at home—effectively out of reach during a hospital admission or emergency. This disconnect means that, in critical moments, clinicians may be unaware of a patient’s preferences, leading to non-beneficial or unwanted treatments and distress for families.

Fragmented digital systems further compound this problem. Many healthcare providers operate within siloed electronic medical record (EMR) platforms that do not communicate with each other. As a result, ACPs are not seamlessly shared between community and acute care settings, undermining continuity and coordination of care.

Staff Training and Privacy Concerns

Lack of staff training is another significant barrier. Without adequate education on the importance of ACPs and how to access or interpret them, clinicians may overlook these documents or feel unprepared to integrate them into care planning. Additionally, concerns about privacy and consent can lead to hesitation in sharing ACPs across care teams, even when it is in the patient’s best interest.

Facilitated ACP Services: Empowering Patients and Clinicians

Facilitated ACP services play a vital role in overcoming these obstacles. By providing structured support and education, these services empower both patients and clinicians to engage in meaningful conversations about care preferences. They also ensure that ACP documentation is completed accurately and stored in a way that is accessible across care settings.

• Education: Ongoing training for clinicians on the value and use of ACPs.
• Empowerment: Supporting patients to articulate and document their wishes.
• Integration: Embedding ACP discussions into routine care and discharge planning.

Policy and Clinical Governance: Driving Digital ACP Adoption

Healthcare leadership is instrumental in driving system-wide improvements. Clinical governance frameworks must prioritise the adoption of digital ACP tools and set clear expectations for their use. Policies should address privacy concerns by establishing robust consent processes and secure access protocols. Quality improvement initiatives can monitor ACP accessibility and guide ongoing enhancements.

“Our hospital used to struggle with lost or inaccessible ACPs. After adopting a digital platform and embedding ACP checks into our admission process, we saw a marked reduction in unwanted interventions and greater family satisfaction.” – Director of Nursing, Metropolitan Hospital

The Emerging Standard: Interoperable, Patient-Centred ACPs

Best practice is rapidly shifting towards digitally accessible, interoperable ACPs. The Evaheld ecosystem exemplifies this standard. At its core, the patient’s Legacy Vault securely stores their ACP. With explicit patient consent, healthcare providers can be granted time-limited, secure access via a simple share function. This critical interoperability layer bridges the gap between community and acute care, ensuring that patient-centred care is not just an aspiration, but a practical reality.

By addressing healthcare system barriers through education, policy reform, and adoption of advanced digital tools like Evaheld, clinical governance teams can significantly improve ACP accessibility. This leads to better patient outcomes, reduced non-beneficial treatments, and a more ethical, person-centred approach to care.

Envisioning the Future: Enhanced Patient-Centred Care through Proactive ACP Engagement

Advance Care Planning (ACP) is a cornerstone of ethical, clinically excellent, and truly patient-centred care. Yet, despite its recognised value, a persistent challenge remains: even when an ACP exists, it is often inaccessible at the point of care. Too frequently, these crucial documents are left in a paper file at a general practice or stored at home, rendering them useless in urgent hospital settings. This disconnect undermines the intent of ACP—ensuring that patient values and preferences guide care, especially when individuals are unable to speak for themselves.

The Case for Proactive Engagement in Advance Care Planning

Proactive engagement in ACP conversations, well before a health crisis, is essential for developing meaningful, personalised care plans. Research consistently shows that early ACP discussions result in care that is more closely aligned with patient values and wishes. In fact, studies indicate that two-thirds of U.S. adults lack an advance directive, highlighting a significant gap in preparedness. When patients are involved early and supported through the process, ACP completion rates rise, and the resulting plans are more comprehensive and reflective of individual priorities.

Proactive engagement also reduces the risk of non-beneficial or unwanted treatments, particularly in acute care settings. By clarifying patient preferences ahead of time, clinicians can avoid interventions that may not align with the person’s goals, while families experience greater satisfaction and less decisional conflict. This approach supports ethical decision-making and upholds the principle of patient autonomy, which is central to high-quality, patient-centred care.

Digital Platforms: Enabling Ongoing Updates and Shared Decision-Making

The future of patient-centred care lies in the seamless integration of digital platforms that facilitate ACP completion and ongoing engagement. Digital solutions allow patients and their families to revisit and update care preferences as circumstances change, ensuring that ACPs remain current and relevant. These platforms also support shared decision-making by enabling patients, families, and clinicians to collaborate in real time, regardless of location.

Integration with electronic health records (EHRs) is a critical advancement, streamlining clinical workflows and ensuring that ACPs are readily available to treating teams. This interoperability eliminates the risk of lost or outdated documents and embeds ACP into routine care delivery, rather than treating it as an isolated process. As a result, clinicians are empowered to deliver care that is both clinically appropriate and ethically sound.

The Evaheld Ecosystem: Bridging Community and Acute Care

Evaheld’s ecosystem exemplifies the emerging best-practice standard for accessible, proactive ACP engagement. At its core is the patient’s Legacy Vault, a secure digital repository for advance care plans and related documents. With explicit patient consent, healthcare providers can be granted secure, time-limited access to view ACPs via Evaheld’s share function. This critical interoperability layer bridges the traditional gap between community and acute care, making patient-centred care a practical, everyday reality.

Scenario: Transforming a Patient’s Care Journey

Consider a scenario where a patient, supported by their GP, completes an ACP using a digital platform like Evaheld. The patient’s preferences are stored in their Legacy Vault and can be updated as needed. When the patient is admitted to hospital unexpectedly, the treating team can access the ACP instantly—with the patient’s consent—ensuring that care aligns with the individual’s values from the outset. Family members are reassured, clinicians are guided by clear directives, and the patient’s voice remains central, even in crisis.

Driving Innovation and Leadership in Patient-Centred Care

As the healthcare sector moves towards a future where digital ACPs are the norm, clinical governance leaders, nursing directors, and medical executives are called to champion innovation. Adopting digital, facilitated ACP services not only improves patient outcomes but also strengthens ethical care and enhances the overall healthcare experience. Early engagement, digital accessibility, and robust interoperability are the pillars of a patient-centred future.

Conclusion: Making Accessible Advance Directives the Norm for Ethical, High-Value Care

Advance care planning (ACP) is a cornerstone of ethical, high-quality, and patient-centred care. Yet, the persistent challenge remains: even when a patient has thoughtfully completed an advance care plan, it is too often inaccessible at the critical moment. ACPs are frequently left in paper files at a general practice, or at home, rendering them invisible and ineffective in hospital emergencies or acute care settings. This gap undermines the very purpose of advance care planning, which is to ensure that care aligns with the patient’s values, preferences, and wishes—especially when they are unable to speak for themselves.

Accessible ACPs are essential for achieving key clinical goals. When clinicians can quickly access a patient’s advance directive, they are empowered to reduce non-beneficial or unwanted treatments, avoid unnecessary interventions, and support families during difficult decision-making. This not only improves family satisfaction with care but also upholds the highest standards of ethical decision-making. The availability of ACPs at the point of care supports clinicians in making choices that respect patient autonomy and dignity, reinforcing the principles of patient-centred care and clinical governance.

The landscape of healthcare is shifting towards a new standard of care, where digitally accessible ACPs are no longer a luxury, but a best-practice expectation. Digital platforms, such as the Evaheld ecosystem, are at the forefront of this transformation. Evaheld acts as a critical interoperability layer, bridging the divide between community and acute care. Through the patient’s secure Legacy Vault, ACPs can be stored safely and shared with healthcare providers via a consent-driven, time-limited access function. This ensures that, regardless of where a patient presents—be it a hospital, aged care facility, or general practice—their wishes are both visible and actionable.

Overcoming the barriers to accessible ACPs requires more than just technology. It demands leadership from clinical governance managers, directors of nursing, and medical executives. Education and policy support are vital to embed ACP accessibility into everyday practice. Healthcare leaders must champion the integration of digital ACP solutions, ensuring that staff are trained, systems are interoperable, and patients are empowered to participate in their own care planning. The evidence is clear: accessibility of ACPs is fundamental for ethical, quality healthcare, and digital tools are critical to advancing patient-centred care.

The future of quality clinical governance lies in embracing technology that empowers both patients and providers. By prioritising integrated, facilitated ACP services, healthcare systems can ensure that advance directives are not only completed, but also readily available when needed most. This shift will lead to improved patient outcomes, greater satisfaction for families, and more confident, ethically sound decision-making for clinicians. In doing so, healthcare organisations will fulfil their responsibility to deliver care that is truly aligned with the patient’s wishes and values.

In summary, making advance care planning easily accessible is not just a technical challenge—it is an ethical imperative and a measure of clinical excellence. As digital solutions like Evaheld become embedded in routine practice, they offer a practical pathway to bridge the gap between intent and action. It is now up to healthcare leaders to drive this change, ensuring that accessible advance directives become the norm for ethical, high-value care across Australia’s health system.

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TL;DR: Advance care plans must be readily accessible to truly align care with patient preferences. Digital solutions like Evaheld's Legacy Vault bridge the gap, empowering clinicians and families with timely, ethical access to these vital directives.