Successful implementation of advance care planning requires culture change and a whole-of-system approach. The following steps and resources will assist you to implement advance care planning and shared goals of care in your area.

Our interactive advance care planning services map contains an email contact in your local district health board (DHB) to support your advance care planning implementation efforts, as well as an indication of the DHB process for uploading advance care plans.

Having clinical staff who are skilled and confident to support people with advance care planning is essential. Training alone will not create sustainable change in practice. We need trained clinicians to have the conversations and use the information gathered to inform care. This requires the development of a system within your DHB or clinical area that includes all of these key elements:

  • leadership to champion for the programme and source people and resources that might be required
  • a process for identifying people who would benefit
  • clinicians supported to engage in the conversations with time, training and mentoring
  • patients and their whānau supported before, during and after these conversations
  • conversations documented effectively to inform care/treatment that aligns with what is important to the person and their whānau
  • process to share and review plans with the person and with other health care providers
  • process to ensure what is important to the person and their whānau is used in care planning and delivery
  • process to review and continuously improve your advance care planning and shared goals of care practices.

 

Related resources

Resource: Advance care planning implementation guide for DHBs

Resource: Serious Illness Conversation Guide implementation guide

Resource: Shared goals of care preparation and implementation guide (document to come in March)

Resource: L1A training administration manual

Resource: Serious Illness Conversation Guide training administration manual

Resource: DHB-specific contacts and process for recording advance care plans

Last updated 05/02/2021