Advance care planning (ACP) gives everyone a chance to say what’s important to them. It helps people understand what the future might hold and to say what treatment they would and would not want. It helps people, their families and their healthcare teams plan for future and end of life care.

This makes it much easier for families and healthcare providers to know what the person would want - particularly if they can no longer speak for themselves. It also provides some peace of mind as the person identifies and clarifies what they want in their future care and that these wishes can be made known, even if they can no longer speak for themselves.

ACP is for everyone

Everyone should take some time to think about what’s important to them in their future health care, even those who are still young and healthy. You don't know when you may have a medical crisis and will be unable to speak for yourself.

When to start thinking about ACP

Any time is a good time to think about what’s important to you about your future health care. However, ACP becomes even more important when you have some health problems, have been diagnosed with a disease or illness, are getting older, or have strong views about what you do and don’t want.

Identifying patients who may benefit from ACP

Clinicians should initiate ACP conversations with patients:

- who specifically ask about advance care planning

- who ask about their future health care

- who have a serious illness which is potentially life threatening

- who have a chronic illness where the answer to the following question is “yes”: “Would I be surprised if this patient was alive in 12 months?"

People requiring special consideration

Effective ACP depends on the person being able to communicate with healthcare professionals and to make choices and decisions about their future health care. For some individuals and groups, ACP will therefore present particular challenges and for others, of course, it will simply not be possible.

Individuals for whom special considerations must be made in the ACP process include:

- People with mild cognitive impairment

- People with intellectual impairments

- The visually impaired person

- The deaf person

- The deaf and blind person

- People with physical impairments

- People with speech impairments

Tools and techniques that can be employed to ensure effective communication with these groups can be found in the Ministry of Health publication, “Advance Care Planning: A guide for the New Zealand health care workforce”.

People with advanced cognitive impairment including dementia

ACP relies on the patient being competent to share in the planning process and so needs to be considered early in the care of any person for whom the diagnosis of dementia is suspected. A person with advanced dementia will be unable to participate in ACP and in this situation; alternative decision-making approaches have to be applied.

​The predominant focus of the ACP is what is important to the person/patient. It can however record important information that is relevant to clinicians and the care they provide, as follows:

‘Section 4 of the ACP – If I am unable to make decisions’ – stores information about the patients EPOA (Enduring Power of Attorney) if they have one.

‘Section 5 of the ACP– When I am dying’ – stores information about patient wishes if they are dying such as stopping medications or where they would like to die.

‘Section 6 of the ACP – My treatment care and choices’ – stores information about what treatment a patient may or may not want. This section is important if a quick decision is needed in an emergency situation such as ‘for resuscitation or not’. This section also includes any Advance Directives.

The tools we use for ACP include:

- My Advance Care Plan

- He Waka Kakarauri

- SICG (Serious Illness Conversation Guide)

- SGOC (Shared Goals of Care)

- Te Ara Whakapiri

The Whānau Tahi ACP tool is used to store, access and update ACPs.

Each of these tools has a different function as a part of ACP and is described in each of the links above.

The preferred place to create, store and edit Advance Care Plans in Northland is the Whānau Tahi ACP tool. Click here for information about Whānau Tahi and how it is used in Northland.

Whānau Tahi can be accessed in the following ways:

• The patient/person - via the Shared Care Patient portal
• Whānau - via the Shared Care Patient portal
• Secondary Care Hospital Services (via Concerto or secure web access)
• GP Practices (via Medtech or MyPractice)
• Iwi Providers - via secure web access
• Other Primary Care Services - via secure web access

• Community Pharmacies (via Toniq and RxOne)
• ARC facilities (via Concerto)
• NGO’s - via secure web access

Note: While the Shared Care Patient Portal is available on the internet, Whānau Tahi via the web is only available from within the Connected Health Network.

Whānau Tahi stores information about what is important to the patient. The paradigm used is that the patient should be the centre of the care they receive; this is done in Whānau Tahi by becoming a member of their care team. Once a member of their care team you can access their record as needed.

Patients who have access to their portal can grant and revoke portal access to others (such as whānau members) as they wish. From the portal, patients are also able to view who has accessed their record, when they did and what if any changes they made.

The Whānau Tahi tool is tool was approved regionally (by the 4 Northern DHBs) for Shared Care Planning in 2016. At that time, in Northland, the decision was made to have the records of all patients who are registered with a GP Practice within the Mahitahi area (was then Te Tai Tokerau and Manaia PHO areas) uploaded into Whānau Tahi.

In late 2019 an ACP project was approved by the NDHB ELT (Executive Leadership Team) with Whānau Tahi being the preferred/chosen software tool to store ACPs.

One of the reasons for its preference is that Whānau Tahi is used to store Shared Care Plans and ACPs are a natural progression from that. Plus the ACP can build on what has already been stored in the Shared Care plan. The majority of the 9000 Shared Care plans in Whānau Tahi are for those who are registered with the Ki A Ora Vision Primary Care programme.

Another reason is because Whānau Tahi is accessible at most health providers throughout Northland and is also available to patients where-ever they have an internet connection. The licensing allows for an unlimited number of users at no extra cost.

The third reason is that Whānau Tahi already has an ACP module which required no additional technical work to be able to use.

If you have a patient with a written ACP (on paper) – there are various ways to have this added into Whānau Tahi. Although it is possible to upload a scanned document into Whānau Tahi, the preferred option is to add ACP information directly into the ACP template. This makes the content of the ACP more accessible such as in an emergency situation. This is because they are then displayed in the Whānau Tahi summary report (available from the Shared Care Record button on the Concerto Patient Demographics screen).

Options for transferring the written ACP into Whānau Tahi include:

- Giving the patient access to the portal so they can add into the ACP template themselves

- The patient giving access to the portal to a Whānau member who may add in the plan (alongside the patient)

- If you as a health worker have access to Whānau Tahi, you could add ACP for the patient (with the patient present to check you are interpreting their wishes correctly)

- If these options are not suitable, contact can be made with the ACP administrator at acp@norhlanddhb.org.nz who will be able to work out a way to get the plan into the Whānau Tahi ACP.

Everyone who is registered with a GP Practice within the Mahitahi Hauora area will have a record in Whānau Tahi. Anyone who has access to the Whānau Tahi tool is able to give a person who has a Whānau Tahi record, access to their own portal. Click here for instructions on how to do this.

Click here for ​Northland DHB L1 ACP training courses. Once on this page, type ACP in the ‘Course Name’ field and click on search. You will need to have a login to access these courses on LEARN.

Click here for ​Northland DHB L1A ACP 1 day training courses. Once on this page, select 'Advance Care Planning L1A Workshop' from the drop down ‘Course’ field and click on search.

Click here for HQSC (Health Quality & Safety Commission) training resources for health staff.

Information about upcoming training courses can also be provided by the NDHB ACP Administrator who can be contacted at acp@northlanddhb.org.nz.

In Northland, two ACP models are available to be used. The ‘My Advance Care Plan’ format which is a national standard and the He Waka Kakarauri Maori model.

The ACP form in the Whānau Tahi tool uses the national standard format which is then available to be viewed in Concerto by clicking on the Shared Care button in the patient demographics screen. This read-only view is available for all Concerto users who have clinical access (whether or not they have Whānau Tahi access). The editable version is also available via Concerto for those with Whanau Tahi access (with permission from the patient).

Although work is happening to make the He Waka Kakarauri model available electronically in Whānau Tahi, at present it is not. If this model is used, it will need to be recorded either on paper or electronically outside of Whānau Tahi and uploaded as a document into Whānau Tahi so it is then available where ever Whanau Tahi is available.

Patients can choose to use either or both ACP models if they choose.

​If you need more information than what is on these pages and their links, the person to contact is the Northland DHB ACP Administrator. Email acp@northlanddhb.org.nz.