Why planning for future health care matters, and how GPs can support it

When someone suddenly becomes seriously unwell, many clinicians and families find themselves having to make high‑stakes decisions without a clear understanding of what the person themselves would have wanted. For Paul, 71, a sudden cardiac arrest changed everything. When Paul was unconscious in the following days, his wife Heather found comfort and relief in their advance care planning (ACP): “We were under so much stress. Knowing his wishes meant I didn’t have to make those decisions alone.” 

Paul described how his advance health directive is “a true gift, something that speaks when you can’t”. 

“It gave confidence and certainty to Heather and our family,” he said.

With Australia’s increasing life expectancy and the increasing prevalence of chronic and complex illness, many people are likely to find themselves in Paul and Heather’s situation. Dementia is now the leading cause of death, meaning that many more Australians will experience impaired decision-making and require healthcare decisions to be made by others. 

ACP gives peace of mind and eases the burden on decision-makers. It improves satisfaction with care and communication with health professionals. It reduces distress for families and can reduce unwanted treatments and interventions.

Despite these benefits, engagement remains low. Advance Care Planning Australia (ACPA)’s 2025 national prevalence study showed that just one in three Australians have engaged in any kind of ACP, and only 6% have completed a formal advance care directive. 

Busting the myths

A common myth about ACP is that it’s a “difficult” conversation and people don’t want to talk about it. In fact, ACPA’s 2025 national prevalence study showed that four out of five Australians (79%) agree that ACP helps reduce confusion, stress and anxiety; and three out of four (73%) are open to talking about it.

It’s often perceived that ACP is only for older people or at end-of-life. As Paul’s story shows, ACP is most valuable when done early — before it is needed.

Another common belief is that ACP is too time consuming and complex. Starting the process can be a simple as a conversation: “If you became seriously unwell, what would be most important to you?” It does not have to be done all at once and does not have to involve formal legal documents.

What can and should GPs be doing? 

General practitioners (GPs) are ideally positioned to support people with the ACP process, assisting people to start the process early, well before a health crisis, in an environment of trust. However, GPs also report barriers to ACP engagement including: lack of clarity about who should initiate the discussion (the patient or the GP); lack of time, lack of skills or confidence, lack of systems to support sharing ACP information; and lack of funding.

ACPA resources provide strategies and supports to help GPs overcome these barriers.

1. Initiating the discussion

Given we know that most people are open to a conversation about ACP, GPs can be confident that a gentle invitation to consider ACP is likely to be well-received. The more that ACP conversations are built into routine care, the more ACP will be seen as just another preventive health intervention; one that empowers people to exercise their rights and express their values and preferences. 

Providing information and an invitation to consider ACP is clearly important when a patient is diagnosed with a life-limiting illness or has a chronic condition which is getting worse. Consider including an ACP conversation during appointments for annual flu vaccinations, preparation or review of management plans or health assessments. 

2. Lack of time

It’s not the GP’s job to “do” ACP, it’s a patient-led activity. It doesn’t have to take a lot of time in the consulting room, and it doesn’t have to be completed in one visit. GPs and other practice staff can provide information, useful prompts, and clarification for patients, who will likely want to spend time reflecting on their wishes and preferences and discussing them with trusted people in their life. 

3. Lack of skills or confidence

Free online learning about ACP is available from ACPA and the RACGP. The Advance Project also has structured conversation guides to help GPs develop confidence in ACP discussions. 

4. Lack of systems to support sharing ACP information

ACP can only guide future care if information and documents are able to be accessed when needed. While there is further work to be done to improve Australia’s digital health systems, GPs can support visibility of ACP information by advising patients to share their ACP documents with their substitute decision-makers, care providers, and upload them to My Health Record (check also for state-based registries). Some GP software allows direct upload of patient’s ACP documents into My Health Record by the GP.

5. Lack of funding

ACPA has a new Factsheet which provides guidance on embedding the ACP process in general practice. Options to use MBS items to support ACP include time-tiered general attendance items, management plans and health assessments, and practice nurse items. 

Australians are open to ACP conversations, and general practice is uniquely placed to support them, before a crisis strips people of the chance to speak for themselves. ACP helps ensure that future health care reflects the person at the centre: their values, their relationships, their life story. 

As Paul says: “Life can change in an instant. Plan ahead.” 

Dr Catherine Joyce is the National Manager of Advance Care Planning Australia, where she oversees national initiatives to inform the community, educate the health and aged care workforce, build capability across services, and advocate for system‑level improvements that support advance care planning. She is an Adjunct Associate Professor in the School of Public Health at the University of Queensland. With a background in clinical psychology and extensive experience in health services research and senior leadership roles across health, aged care, community services and government, she is committed to strengthening evidence‑informed policy and ensuring people have a voice in decisions about their health and wellbeing.