Care planning establishes the care goals and needs of the person, their family and carers. Individuals should be involved as much as possible in their care planning, to ensure their preferences and needs are reflected. Recognising variation in community and cultural preferences and expectations of care will help to support a person-centred approach for all. Multicultural health and Aboriginal health professionals can provide cultural guidance and support and, where applicable, be part of the multidisciplinary team.
Processes are in place to ensure that following comprehensive assessment of people with life-limiting illnesses, the person, their family and carers are actively involved in discussions and decisions regarding immediate care needs and advance care planning.
Appropriate documentation must reflect these decisions.
Care planning is important to support meeting the goals and needs of the person with life-limiting illness, their family and carers.
Advance care plans must be readily available for current and future care providers, including during unplanned and out-of-hours care (including formal documents, such as advance care directives).
Advance care planning information and resources are available on the NSW Health website and tools such as the End of Life electronic medical record (eMR) solution can improve shared care planning across multiple settings.
Care plans need to be communicated with the person’s general practitioner and original referrer.
Processes must be in place to ensure periodic reassessment of patient and family/carer needs, as these needs may change over time. This includes the provision of relevant health literate information.