Supporting GPs Advance Care Planning Conversations

Advance care planning (ACP) can feel daunting for many practitioners, but it’s an essential conversation that shapes patients' futures and eases decision-making during serious illness. Imagine a scenario where a GP, during a routine annual check-up, gently introduces the topic by saying, "As part of your overall health planning, it's helpful for me to understand what's important to you if you become seriously unwell." This post unpacks practical steps and conversational tools to make ACP approachable, respectful, and incredibly valuable — all while highlighting a modern way to securely document patients’ wishes through the Evaheld Legacy Vault.

Starting the Conversation: Opening Lines and Mindset

Advance Care Planning (ACP) is most effective when it is introduced as a routine part of holistic health care. For General Practitioners, Practice Nurses, and Chronic Disease Management Coordinators, the first step is often the most challenging—initiating a face-to-face discussion that feels natural, supportive, and non-threatening. This section provides practical guidance and conversational scripts to help practitioners confidently start ACP conversations, ensuring patients feel respected and empowered throughout the care planning process.

Normalising Advance Care Planning in Everyday Care

One of the most effective ways to introduce ACP is by framing it as a standard aspect of overall health planning. This approach helps to normalise the conversation, reducing anxiety and stigma for patients. Rather than presenting ACP as something only relevant in crisis or at the end of life, practitioners can weave it into routine care, such as annual wellness or chronic disease management visits. This timing not only increases patient acceptance but also allows for more thoughtful, values-based discussions before any critical health events occur.

Gentle, Value-Focused Opening Lines

Opening lines set the tone for the entire conversation. A gentle, value-focused approach invites patients to share what matters most to them, without feeling pressured to make immediate decisions. Consider using phrases such as:

"As part of your overall health planning, it's helpful for me to understand what's important to you if you become seriously unwell."
"Many people find it useful to talk about their wishes for care, just in case their health changes unexpectedly. Would you be comfortable sharing your thoughts with me today?"

These statements reassure patients that ACP is a routine and proactive step, not a sign of impending crisis. They also emphasise the practitioner's role as a partner in care planning, fostering trust and openness.

Value-Based Questions to Guide the Dialogue

Once the conversation is underway, value-based questions help patients articulate their hopes, fears, and priorities. These questions focus on the person, not just their medical conditions. Examples include:

"If your health declines, what are your most important hopes?"
"What are your biggest worries about your health or future care?"
"Are there things you want your family or doctors to know about what matters to you?"

These open-ended questions encourage reflection and dialogue, laying the groundwork for more specific care planning later.

Distinguishing Values from Medical Decisions

It is important to clarify for patients that this initial conversation is about understanding their general values and preferences, not making immediate medical decisions. Explaining the difference helps reduce pressure and anxiety. For example:

"Today we're just talking about what's important to you and your values. If you ever want to record specific medical decisions, we can help you with that as a next step."

This distinction supports a gradual, patient-centred approach to ACP, where formal directives can be developed over time as needed.

Documenting the Conversation and Recommending Next Steps

After the discussion, it is essential to document the key points in the clinical notes. This ensures continuity of care and provides a reference for future conversations. Practitioners should also recommend a structured next step, such as using the Evaheld Legacy Vault. The Evaheld Legacy Vault enables patients to document their values, preferences, and formal Advance Care Plans in a secure, accessible format. This tool completes the loop started in the clinic, allowing patients and their families to revisit and update their wishes, and ensuring hospitals have access to the most current information in times of need.

Adopting a Supportive, Confidence-Building Mindset

Practitioners play a crucial role in creating a safe and supportive environment for ACP. A calm, empathetic tone encourages openness and reassures patients that their wishes will be respected. One nurse shared that after shifting from a checklist approach to a more conversational style—using open-ended questions and active listening—she noticed patients became more engaged and willing to share their thoughts. This change not only improved the quality of the discussions but also increased her own confidence in facilitating ACP.

Timing and Setting: Choosing the Right Moment

ACP discussions are best initiated during routine, face-to-face visits, such as annual wellness checks or chronic disease reviews. These settings provide a natural opportunity to introduce care planning as part of ongoing health management, rather than as a reaction to acute illness. By embedding ACP into regular care, practitioners help patients feel more comfortable and prepared for whatever the future may hold.

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Dive Into Values: Asking the Right Questions

Advance Care Planning (ACP) is most effective when it begins with a genuine understanding of what matters most to each patient. For GPs and nurses, the first step is to create a safe, open space where patients feel comfortable sharing their beliefs, hopes, and fears. This values-based approach lays the foundation for practical decisions about future care, including the appointment of a Health Care Proxy or the completion of a Living Will.

Starting the Conversation: Opening Lines That Work

Initiating a discussion about ACP can feel daunting, but a simple, empathetic opening can set the right tone. Consider using lines such as:

“As part of your overall health planning, it’s helpful for me to understand what’s important to you if you become seriously unwell.”
“Many people find it useful to talk about what matters most to them in case their health changes in the future. Would you be comfortable sharing your thoughts?”

These statements reassure patients that the conversation is a normal and valuable part of their care, not a sign that something is wrong.

Value-Based Questions: Uncovering Hopes and Worries

Open-ended, value-based questions help patients reflect on their priorities and guide the direction of the conversation. Some effective examples include:

“If your health declines, what are your most important hopes?”
“What are your biggest worries about the future?”
“What does a good quality of life mean to you?”
“Are there situations you would find unacceptable or too hard to live with?”

Using hypothetical scenarios can also prompt reflection without overwhelming the patient. For example:

“Imagine a time when you might not be able to speak for yourself. What would you want your family or doctors to know about your wishes?”

These questions encourage patients to think beyond specific treatments and consider their broader values and goals.

Values Versus Medical Decisions: Clarifying the Difference

It is essential to distinguish between discussing general values and making specific medical decisions. The initial conversation should focus on the patient’s beliefs, preferences, and what gives their life meaning. This is different from completing a Living Will or appointing a Health Care Proxy, which are formal steps that translate these values into actionable directives.

By clarifying this distinction, practitioners can prevent confusion and help patients feel less pressured. For example:

“Today, we’re just talking about what matters most to you. Later, we can discuss how to put your wishes into a formal plan, like a Living Will or choosing a Health Care Proxy.”

Encouraging Reflection on Quality of Life

Encourage patients to consider what makes life meaningful to them. This might include independence, time with family, or the ability to enjoy certain activities. Prompting patients to reflect on these aspects helps ensure that any future care aligns with their values.

Success Story: The Power of Patient-Centred Questions

Consider the case of Mr. L, a patient with advanced heart failure. When his GP asked, “What are your most important hopes if your health gets worse?”, Mr. L shared that being able to recognise and spend time with his grandchildren was his top priority. This insight guided the care team to focus on treatments that preserved his cognitive function. Later, when Mr. L could no longer speak for himself, his family and clinicians were united in honouring his wishes, preventing conflict and distress.

Documenting the Conversation and Next Steps

It is crucial to record the key points of these discussions in the clinical notes. This documentation ensures continuity of care and provides a reference for future conversations. After exploring values, practitioners should recommend the next step: formalising the patient’s wishes.

The Evaheld Legacy Vault is an excellent tool to recommend at this stage. It allows patients to document their values, appoint a Health Care Proxy, and create a Living Will. The platform securely stores these documents, making them accessible to family members and hospitals when needed. By introducing Evaheld, practitioners complete the loop—helping patients move from values-based conversations to concrete, accessible Advance Care Planning.

Practical Tips for Documentation and Follow-Up

Clear and thorough documentation is essential for effective Advance Care Planning (ACP). For GPs and nurses, capturing the details of ACP conversations in clinical notes not only meets documentation requirements but also ensures that patient wishes are respected throughout their care journey. This section provides practical guidance on how to document ACP discussions, support continuity of care, and recommend digital tools such as the Evaheld Legacy Vault to help patients formalise and store their Advance Directive and Medical Orders.

Documenting ACP Conversations: What to Include

When documenting ACP discussions, it is important to record more than just the outcome. Comprehensive notes should reflect the process, context, and content of the conversation. This helps to demonstrate that the discussion was voluntary, informed, and patient-centred. Consider including the following details:

Date and Time: Record when the conversation took place.
Participants: List all individuals present, including family members, carers, or other health professionals.
Opening Statements: Note how the conversation was introduced. For example, “As part of your overall health planning, it’s helpful for me to understand what’s important to you if you become seriously unwell.”
Values and Preferences: Summarise the patient’s responses to value-based questions, such as, “If your health declines, what are your most important hopes? What are your biggest worries?”
Distinction Between Values and Directives: Clearly differentiate between general values discussed and any specific medical decisions or Advance Directives made.
Voluntary Nature: Document that the discussion was voluntary and that the patient received explanations about the purpose and implications of Advance Directives and Medical Orders.
Next Steps: Record any recommendations made, such as completing a formal Advance Directive or using a digital tool for documentation.

Supporting Continuity of Care and Legal Validity

Accurate documentation of ACP conversations supports continuity of care by ensuring that all members of the care team are aware of the patient’s wishes. This is particularly important for patients with chronic or complex conditions who may interact with multiple providers. Detailed notes also provide legal protection for practitioners by demonstrating that the patient’s choices were discussed, understood, and documented in accordance with legal requirements.

When formal Advance Directives or Medical Orders are completed, ensure that copies are stored in the patient’s medical record and that relevant team members are notified. This helps to avoid confusion or delays in care, especially during emergencies or hospital admissions.

Introducing the Evaheld Legacy Vault

Digital tools are increasingly valuable for storing and sharing Advance Care Planning documents. The Evaheld Legacy Vault is a secure, patient-centred platform that enables individuals to document their values, preferences, and formal Advance Directives. By recommending the Evaheld Legacy Vault as the logical next step, practitioners can empower patients to:

Complete their Advance Care Planning documents at their own pace.
Store their wishes and directives securely in a digital format.
Grant access to family members, substitute decision-makers, and hospitals.
Ensure their preferences are accessible in emergencies, supporting continuity and respect for their choices.

Recommending the Evaheld Legacy Vault during follow-up conversations helps to complete the ACP loop started in the clinical setting. It bridges the gap between the initial conversation and the formalisation and sharing of Advance Directives, making it easier for families and healthcare teams to access up-to-date information when needed.

Quick Tips for Integrating ACP Documentation into Workflow

Use standardised templates or checklists for ACP documentation to ensure consistency and completeness.
Allocate dedicated time in chronic disease management appointments for ACP discussions and follow-up.
Flag patients who have initiated ACP conversations for regular review and updates.
Encourage patients to bring family members or decision-makers to follow-up appointments.
After each ACP conversation, provide written information about the Evaheld Legacy Vault and offer assistance with the next steps.

By embedding these practices into daily workflow, practitioners can meet documentation requirements, support patient autonomy, and facilitate access to Advance Directives and Medical Orders across care settings.

Understanding the Legal and Ethical Framework

Legal Foundations of Advance Care Planning

Advance Care Planning (ACP) is underpinned by a range of legal documents designed to ensure a person’s wishes are known and respected if they become unable to communicate. In Australia, the key legal instruments include Advance Directives (sometimes called living wills), appointment of health care proxies (such as Enduring Guardians or Medical Power of Attorney), and specific medical orders like POLST (Physician Orders for Life-Sustaining Treatment) forms. These documents allow individuals to express preferences regarding end-of-life care and palliative care interventions, including resuscitation, ventilation, and artificial nutrition.

It is essential for practitioners to understand the requirements and limitations of these documents, which can vary by state and territory. Advance Directives are legally binding in most jurisdictions, provided they are valid and applicable to the clinical situation. Health care proxies or substitute decision-makers are empowered to make decisions on behalf of the patient, guided by the patient’s documented wishes and best interests.

Roles and Responsibilities of GPs and Nurses

General Practitioners and Practice Nurses play a central role in initiating, documenting, and facilitating ACP discussions. Their responsibilities include:

Raising the topic of ACP as a routine part of chronic disease and palliative care management. For example, opening with, “As part of your overall health planning, it’s helpful for me to understand what’s important to you if you become seriously unwell.”
Exploring patient values and preferences using value-based questions such as, “If your health declines, what are your most important hopes? What are your biggest worries?”
Distinguishing between general values (the conversation) and specific medical decisions (the formal directive).
Documenting the conversation in the clinical notes, ensuring clarity and accuracy.
Recommending the next step, such as formalising wishes in an Advance Directive and storing them securely.

Practitioners must also ensure that the patient’s wishes are communicated to all relevant parties, including family, trusted advisors, and other health care providers. This collaborative approach helps prevent confusion and conflict during critical moments.

Ethical Principles Guiding ACP

Ethical decision-making is at the heart of ACP. The primary principles include:

Autonomy: Respecting the patient’s right to make informed choices about their care, even if those choices differ from the clinician’s recommendations.
Beneficence: Acting in the patient’s best interests, promoting comfort and quality of life.
Non-maleficence: Avoiding harm, which includes not providing unwanted or non-beneficial treatments.

These principles guide practitioners in supporting patients to make decisions that align with their values and beliefs, particularly in the context of end-of-life care and palliative care.

Regular Review and Accessibility of Advance Directives

Advance Directives and related documents should be reviewed and updated regularly, especially after major health events or changes in personal circumstances. It is crucial that these documents are easily accessible to all stakeholders—patients, families, and health care teams—when needed.

To complete the loop started in the clinical conversation, practitioners are encouraged to recommend secure storage solutions such as the Evaheld Legacy Vault. This digital platform allows patients to document their values and decisions, and ensures that the final Advance Care Plan can be accessed by family and hospitals when required. This step supports continuity of care and reduces the risk of miscommunication or lost documentation.

ACP in End-of-Life and Palliative Care Contexts

Advance Care Planning is a core component of end-of-life care and palliative care. It ensures that care aligns with the patient’s goals, reduces unnecessary interventions, and supports a dignified approach to dying. ACP discussions should be ongoing and involve family members or trusted advisors, as their understanding and support are often critical during crises.

Cultural Sensitivity in ACP Conversations

Cultural values and beliefs significantly influence how individuals approach Advance Directives and end-of-life decisions. Practitioners should approach ACP conversations with cultural competence, recognising and respecting diverse perspectives on autonomy, family involvement, and spiritual beliefs. This sensitivity builds trust and encourages honest, open dialogue, ensuring that care plans are truly patient-centred.

Tools and Resources for Effective ACP Conversations

Advance Care Planning (ACP) is a vital component of holistic care planning, especially for patients managing chronic disease. General Practitioners (GPs), Practice Nurses, and Chronic Disease Management Coordinators play a key role in initiating and guiding these conversations. Using the right tools and resources not only builds practitioner confidence but also helps patients feel supported as they consider their future care preferences.

Supportive Tools to Guide ACP Discussions

Several evidence-based resources are available to help practitioners and patients navigate ACP conversations:

Stanford Letter Project: This resource provides patients with simple letter templates to express their wishes, values, and preferences for care. It is particularly helpful for those who find it difficult to start the conversation or articulate their priorities.
PREPARE For Your Care: An interactive online program that walks patients through scenarios and questions, helping them clarify their values and make informed choices about their care. It also provides conversation scripts and educational videos.
Five Wishes: A widely used document that combines legal, medical, personal, and spiritual wishes into a single, easy-to-understand form. It is suitable for a variety of cultural backgrounds and literacy levels.

These tools can be introduced during annual wellness or chronic care management visits, providing a gentle entry point for patients to reflect on their values and preferences. By offering these resources, practitioners can help patients feel more prepared and empowered to document their wishes.

Opening the Conversation: Practical Scripts and Questions

Initiating ACP can feel daunting for both practitioners and patients. Using clear, supportive language helps set a positive tone. Consider these opening lines:

"As part of your overall health planning, it's helpful for me to understand what's important to you if you become seriously unwell."

To explore values and concerns, use open-ended, value-based questions:

"If your health declines, what are your most important hopes?"
"What are your biggest worries about your health or future care?"

These questions help distinguish between general values (the conversation) and specific medical decisions (the formal directive). This distinction is crucial, as it allows patients to first explore what matters most to them before moving on to detailed directives.

Documenting ACP Conversations and Next Steps

It is essential to document ACP discussions in the clinical notes, capturing the patient’s values, preferences, and any decisions made. This record ensures continuity of care and supports shared decision-making among the care team.

After the initial conversation, recommend a structured next step for patients to formalise their wishes. The Evaheld Legacy Vault is a digital platform designed for this purpose. It enables patients to:

Document their values, preferences, and advance care directives in one secure location
Share their ACP documents with family, carers, and healthcare providers
Ensure their wishes are accessible to hospitals and other care settings, completing the ACP loop started in the clinic

By integrating tools like Evaheld with existing resources such as the Stanford Letter Project or Five Wishes, practitioners can offer a seamless pathway from conversation to documentation and storage. This approach supports patients in taking ownership of their care planning and ensures their wishes are respected across all care settings.

Staying Updated: Resources, Billing, and Training

Practitioners should stay informed about the latest ACP resources and digital platforms. Regularly reviewing updates from professional bodies and attending relevant training can enhance communication skills and confidence in facilitating ACP.

Billing codes also support the delivery of ACP services. In Australia, CPT codes 99497 and 99498 can be used for billing ACP discussions during appointments, including annual wellness and chronic disease management visits. Familiarity with these codes ensures practitioners are appropriately reimbursed for their time and expertise.

Ongoing professional development opportunities, such as workshops, online modules, and peer learning, are valuable for building ACP communication skills. These training sessions often include role-play, case studies, and feedback on conversational techniques.

ACP as an Ongoing Process

Advance Care Planning is not a one-time checklist but an ongoing, evolving conversation. Patients’ values and preferences may change over time, particularly as their health status shifts. Practitioners should revisit ACP discussions regularly, updating documentation and supporting patients to review and revise their wishes as needed.

Wild Card: Imagining ACP Through a Patient's Eyes

Advance Care Planning (ACP) is often discussed in terms of forms, legalities, and clinical requirements. But to truly empower patients and strengthen their autonomy, it is vital for practitioners to step into the shoes of those they care for. By imagining ACP through a patient’s eyes, GPs and nurses can transform these conversations from daunting paperwork into meaningful, supportive dialogues about health care wishes and decision making.

Consider the story of Mrs. Taylor, an 82-year-old woman attending her regular check-up with her GP, Dr. Patel. Mrs. Taylor has lived with chronic heart failure for several years, and while she manages well day-to-day, she worries about what might happen if her health suddenly declines. As Dr. Patel reviews her medications, he gently introduces the topic of ACP:

“Mrs. Taylor, as part of your overall health planning, it’s helpful for me to understand what’s important to you if you become seriously unwell. Would you be comfortable talking about your wishes, just so we can make sure your care always aligns with what matters most to you?”

Initially, Mrs. Taylor hesitates. She admits she’s heard about “living wills” but isn’t sure what they mean, and she worries that talking about these things might mean her doctor is giving up on her. Dr. Patel reassures her, explaining that ACP is not about giving up, but about ensuring her voice is heard, no matter what the future holds. He continues with value-based questions:

“If your health declines, what are your most important hopes? What are your biggest worries?”

Mrs. Taylor shares that her greatest hope is to remain at home and maintain her independence for as long as possible. She worries about being kept alive by machines if there’s little chance of recovery. Dr. Patel listens carefully, clarifying that ACP is not just about specific treatments, but about understanding her values and preferences. He distinguishes between the conversation they’re having now—exploring her general wishes—and the formal documentation that can follow.

Through this compassionate exchange, Mrs. Taylor’s initial anxiety gives way to relief. She feels respected and understood, realising that ACP is about dignity and control, not about losing hope. Dr. Patel documents their conversation in her clinical notes, ensuring her wishes are recorded and can guide future care decisions. He then introduces the next step:

“To make sure your wishes are clear and accessible to your family and any hospital you might attend, I recommend using the Evaheld Legacy Vault. It’s a secure place where you can document your values, health care wishes, and any specific decisions you make. This way, your voice will always be heard, even if you can’t speak for yourself.”

Mrs. Taylor is relieved to know there is a practical way to ensure her wishes are respected. She appreciates that the Evaheld Legacy Vault allows her to store her Advance Care Plan in a place that her family and health professionals can access if needed. This gives her and her loved ones peace of mind, knowing that her preferences for care and decision making are clear and protected.

For practitioners, humanising ACP in this way not only builds trust but also leads to better outcomes. When patients are empowered to express their wishes, they experience greater satisfaction and autonomy. Practitioners who approach ACP as a supportive, ongoing conversation—rather than a one-off task—help patients and families navigate complex decisions with confidence and compassion.

Ultimately, Advance Care Planning is not just about paperwork. It is about empowering patients like Mrs. Taylor to make informed choices, to have their voices heard, and to ensure that their health care wishes guide every decision. By seeing ACP through the patient’s eyes and using tools like the Evaheld Legacy Vault, GPs and nurses can complete the circle of care—honouring patient wishes, supporting families, and delivering truly person-centred care.

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TL;DR: This guide equips healthcare professionals with approachable scripts and frameworks to conduct effective advance care planning conversations, highlighting documentation and the Evaheld Legacy Vault for secure storage.

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Supporting GPs With Advance Care Planning Conversations