- Standard 1 – requirement (3)(f)
Intent of this Standard
The Privacy Act 1988 and the Aged Care Act 1997 both permit the disclosure and sharing of health information if the information is necessary to provide health services to individuals, for example, between aged care services and hospital services.
Reflective questions
What practical steps does the organisation take to ensure accurate health information is safely transferred to those providing health care?
- Standard 2 – Purpose and scope of the Standard
Assessment and care planning is expected to provide access to advance care planning including the completion of legally binding advance care directives, and end of life planning, if the consumer wants this.
Organisations need to document the outcomes of all assessments and discussions with the consumer in a care and services plan and set an agreed review date. Care and services plans may include advance care planning, advance care directives, and end of life planning documents.
- Standard 2 – requirement (3)(a)
Intent of this requirement
Where consumers have lost their decision making capacity and have an advance care directive in place, health professionals have obligations to access and enact the advance care directive. It should be available at the point of care and shared across service providers.
Reflective questions
How does the organisation define advance care planning policy and ensure consumers are using quality and complete statutory advance care directive forms?
Examples of actions and evidence
Workforce:
The workforce can describe advance care planning and advance care directives.
Evidence that advance care directive documentation informs end-of-life care and decisions.
Organisation:
Evidence of how the organisation makes sure the workforce has undertaken advance care planning training and has policy to inform advance care directive documentation; ensuring documentation is accurate, up-to-date, complete, shared and stored with relevant healthcare providers.
- Standard 2 – requirement (3)(b)
Intent of this requirement
As part of advance care planning, consumers may wish to complete an advance care directive detailing their care preferences or appointment of a substitute decision-maker. Advance care directives are legally binding documents, which can only be completed by a competent consumer who still has decision-making capacity.
If a consumer is unable to document an advance care directive due to lack of decision making capacity, a medically driven document outlining the plan of care in relation to emergency treatment or severe clinical deterioration can be useful (e.g. acute resuscitation plan, do not resuscitate order). This document should be developed in consultation with the substitute decision-maker of a consumer without decision making capacity.
Where a consumer lacks the capacity to make decisions, providers will need to check if they have previously appointed a substitute decision-maker (e.g. attorney, guardian). All states and territories have a default decision-maker (e.g. partner, eldest child, or carer) with the exception of the Northern Territory. If no substitute decision-maker can be identified, they will require a court or tribunal appointed guardian to make medical decisions.
Examples of actions and evidence
Consumers have access to advance care planning and end-of-life planning.
If a consumer chooses to complete an advance care directive, it is done while they still have decision making capacity.
The workforce can describe advance care planning and understand the substitute decision-maker should be consulted in medical decisions including consent, refusal and/or withdrawal of treatment.
Advance care directive documentation should be accurate, up-to-date, complete, shared and stored with relevant care and service providers.
- Standard 2 – requirement (3)(d)
Intent of this requirement
Care and services plans may include advance care planning, advance care directives, or end of life planning documents.
- Glossary – Advance care directive:
A written advance care planning document completed and signed by a competent consumer who still has decision-making capacity. In Australia, advance care directives are recognised by specific legislation or common law. Advance care directives can record the person’s preferences for future care and/or appoint a substitute decision-maker to make decisions about the person’s health care.
- Glossary – Advance care planning:
The process of planning for future health and personal care, whereby the person’s values, beliefs and preferences are made known so they guide decision-making at a future time when that person cannot make or communication their decisions.
- Standard 5 – requirement (3)(b)
Intent of this requirement
The service environment is expected to promote the free movement of consumers (including to access outdoor areas). It may be important that the service environment is secure or access to certain areas are restricted to help create a safe service environment for consumers.
Arrangements to protect consumers require assessment, documentation in care and services plans, informed consent from the consumer and regular monitoring and review, in line with best practice and legislation.
