For health professionals

The HQSC Shared Goals of Care Plan contains information about recognising and responding to acute deterioration and the importance of having shared goals of care discussions with patients and their whānau.

Download the shared goals of care case for change

Find additional resources and get the HQSC Shared Goals of Care guide.

Check with your colleagues to see if they have any experience with Advance Care Planning. About 70 people in the Bay of Plenty have completed the ACP training so far and are dotted around the organisation.

A good place to start is HQSC's Advance Care Planning (ACP) webpage. Here you can complete the online self-assessment and then try the introductory modules.

There are also a couple of tools that may be useful. The first is the Serious Illness Conversation Guide that comes from Ariadne Labs in the United States of America. It's a series of eight questions that have been tested on patients and can help get the information you want.

Atul Gawande (author of Being Mortal) has refined the questions even further and created Five Questions:

1. What is your understanding of where you are and of your illness?
2. Your fears or worries for the future?
3. Your goals and priorities?
4. What outcomes are unacceptable to you? What are you willing to sacrifice and not?
   And later,
5. What would a good day look like?

The libraries at both Tauranga and Whakatāne hospitals have books about this as well.

The Aotearoa serious illness conversation guide forms part of the Commission's serious illness conversation programme, supported by district health boards.

The guide is a set of structured questions to help clinicians who do not come from a palliative care background, have conversations with seriously ill people and their whānau about what is most important to them if time were limited and/or their functional abilities were to change.

Download the Aotearoa serious illness conversation guide

Find comprehensive resources for serious illness discussions at the HQSC website

The Aotearoa drill sheet to support serious conversations is part of the Commission's serious illness conversation programme, supported by district health boards.

Download the drill sheet to support serious illness conversations

Find comprehensive resources for serious illness discussions at the HQSC website

'Just in Case’ plans aim to improve the experience and outcomes of palliative and end-of-life patients by developing a plan around their future needs, wishes and quality of life considerations.

This patient-held plan can be referred to by whānau and caregivers, and used by other healthcare providers to enable a more integrated and seamless approach to palliative care closer to home.

The objective is to increase the provision of primary palliative care in the community through proactive plans and improved service integration, and reduce hospital transfers whenever possible and appropriate.

Just in Case plans should be developed between the patient and a clinician who knows them well, such as with the GP or their NP. However, hospital clinicians can develop a temporary plan to facilitate this right care process, and request for the GP or NP to review and countersign or change the plan within two weeks.

• Download temporary hospital 'Just in Case' plan
• Download the 'Just in Case' user guide

Medical Care Guidance to support the development of a parallel process to ACP for patients who permanently lack capacity.

Download Medical Care Guidance