The Society

Why is Advance Care Planning so important?

Advance Care Planning is vital to ensure not only that each person we care for has their right to choose how they wish to be cared for as they approach the end of their life, whether they are able to communicate at that time or not; but also to health economies struggling with escalating health budgets and growing dissatisfaction from health consumers wishing to have more say in their health.


Constitution in German and English as updated by Special Resolutions of the Society’s Annual General Meeting held on 6th Sptember 2017:

Satzung der Gründungsversammlung intern. Gesell. f. Behandlung im Voraus planen

Read more on how to become a member on the membership page.

Practice tools

  1. Patient Information
  2. Facilitator / Instructor Training
  3. Facilitation Processes
  4. Forms (Written Documentation of Advance Care Plans)
  5. Quality Assurance Systems or Evaluative Frameworks
  6. Regional Implementation Strategies / Change Management Policies

Advance Care Planning Programs

The concept of ACP programs arises from the understanding that it requires a systematic approach to implement and maintain ACP in a specific health care setting (facility, region, nation etc) so that patients’ wishes are known and can be followed. Essentially, ACP programs rest on two pillars:

a) On the individual level, providing a communication process as described above, facilitated by skilled non-physician and physician staff.

b) On the system level, ensuring there are processes for patients to be offered ACP, and to allow patients to record their wishes in a standardized way so they can be stored, retrieved as required and ultimately allow the person’s wishes to be known and respected. Thus health care services need to have appropriate policies and systems in place. Additional components of successful programs include staff education, defined roles and expectations of physicians, and adequate training for advance care planning facilitators, doctors and other members of the health care team. Successful ACP programs are usually proactive, appropriately timed, and integrated into usual care. Program evaluation and ongoing development and refinement of programs are also important. Finally advance care planning programs need to ensure that as patients move across health care settings, documentation of their wishes and goals of treatment travels with them.

Essential elements of advance care planning programs:

Modification to “Five Promises” (Respecting Patient Choices) as suggested by beizeiten begleiten (“Seven Elements”):

1. Initiate conversations about ACP with all adults who need to plan.
2. Skillfully facilitate planning with each individual
3. Provide professional written documentation
4. Make sure all plans are available when needed

5. Actively support continual actualisation of the plan and / or disease-specific planning in the trajectory
6. Follow plans in a thoughtful and respectful way
7. Install a process of continual quality assurance

The Goals of Advance Care Planning and Establishing an Evaluative Framework

Currently there are no accepted standards or evaluative framework for ACP; however, work in this area is evolving. In principal, there should be a common set of goals used to evaluate the effectiveness of any ACP program or system. These agreed upon goals will assist with consistent measurement across programs.

Common Goals of ACP

1. Enhance patient and family understanding of their illness including prognosis, the full range of treatment options, and the likely outcomes of these treatment options.
2. To create an effective care plan that includes
a. The selection of a well-prepared healthcare agent when possible
b. Specific instructions that reflect informed decisions geared to a person’s state of health or illness


Respecting Patient Choices:
The Respecting Patient Choices (RPC) advance care planning program is based on the Respecting Choices® program first developed by Gunderson Lutheran Medical Foundation in La Crosse, Wisconsin, USA. RPC was introduced into Austin Health (Melbourne, Victoria) as a pilot program supported by the National Institute of Clinical Studies, an initiative of the Australian Government Department of Health and Ageing. The program has subsequently been extended to further areas within Austin Health, residential aged care facilities in both rural and metropolitan areas, Divisions of General Practice and several interstate health services.

Gold Standards Framework:
The Gold Standards Framework (GSF) is a systematic evidence based approach to optimising the care for patients nearing the end of life delivered by generalist providers. It is concerned with helping people to live well until the end of life and includes care in the final years of life for people with any end stage illness in any setting.
The National GSF Centre CIC is the national training and coordinating centre for all programmes, enabling generalist frontline staff to provide quality care for people nearing the end of life, whatever their illness, wherever the setting. It aims to support best implementation of GSF in all settings, using a common framework and toolkit of resources.
GSF improves the quality, coordination and organisation of care in primary care, care homes and acute hospitals. This enables more patients to receive the type of care they want, in their preferred place, with greater cost efficiency through reduced hospitalisation.

End of Life Journal:
The free online journal for nurses caring for dying people at home, in hospitals and care homes.