Advisory No: A 15/02
TITLE
Advance care directive assessment requirements
in low risk environments
VERSION
Version 1.0
DATE OF
PUBLICATION
8 September 2015 - TBC
REPLACES
n/a
STATUS
Active
COMPLIANCE
Mandatory
APPROVED FOR
DISTRIBUTION BY
COO
REVIEW DUE DATE
September 2017
INFORMATION IN
THIS ADVISORY
APPLIES TO:
All approved accrediting agencies
Health service organisations including day procedure services,
rehabilitation and mental health services.
KEY RELATIONSHIP
Standard 1 and Standard 9
RESPONSIBLE
OFFICER
Margaret Banks
Senior Program Director
CONTACT DETAILS
Phone: 1800 304 056
Email: accreditation@safetyandquality.gov.au
TRIM NO.
D14-15499
LINKAGES TO
OTHER
ADVISORIES and/or
DOCUMENTATION
A13/07 Advice provided to accrediting agencies on non applicable
actions.
ATTACHMENTS
NOTES
(if applicable)
Advisory No: A15/02
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Advisory No: A15/02
Advance care directive assessment requirements
in low risk environments
PURPOSE:
To clarify the implementation requirements for advance care directives (ACDs) in health
service organisations where the risk of harm to patients is consistently low because of the
patient selection criteria and/or the treatment provided is low risk.
ISSUE:
The Australian Commission on Safety and Quality in Health Care (the Commission) has
been advised that the implementation requirements for ACDs in low risk environments
require clarification. Three actions relate to ACDs, they are:
Action 1.18.4
Action 9.8.1
Action 9.8.2
Patients and carers are supported to document clear advance care
directives and/or treatment-limiting orders
A system is in place for preparing and/or receiving advance care plans in
partnership with patients, families and carers.
Advance care plans and other treatment-limiting orders are documented in
the patient clinical record.
A low risk environment is one in which, the care is uncomplicated and the likelihood that
clinical deterioration resulting in death or harm is very low, and where the health service
organisation can demonstrate there have been no or very few incidents of patients requiring
treatment for clinical deterioration.
Advisory A13/07 Advice Provided to Accrediting Agencies on Non Applicable Actions, states
that Action 1.18.4 could be ‘non applicable’ if the health service organisation can
demonstrate there is a low risk of patient harm from care provided by that service. Similarly,
for health service organisations operating in a low risk environment, Actions 9.8.1 and 9.8.2
could be ‘non applicable’ where there is evidence of minimal or no risk that their patients’
clinical condition will deteriorate.
A patient’s health condition or their co-morbidities may place them at high risk of clinical
deterioration. Pre-admission screening processes and patient assessment should be used to
determine if a patient is suitable for care in a low risk health service organisation.
REQUIREMENTS:
It is not intended that every patient admitted to a health service organisation operating in a
low risk environment will be asked to provide a copy of an ACD on admission. However, to
implement Actions 1.18.4, 9.8.1 and 9.8.2, the Commission expects the organisation will
have a policy and supporting protocols and procedures that:
 describe the mechanism for accepting and documenting an ACD and/or treatment limiting
orders when a patient is admitted who voluntarily provides this information
 notify the treating doctor that an ACD has been received
 expect the treating doctor to discuss with their patient the risks of the procedure and
actions that may be taken should an adverse incident or clinical deterioration occur
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 ensure the ACD is included in the clinical handover information should a patient’s clinical
condition deteriorate and there is a need for care to be transferred to another health
service organisation.
In addition, health service organisations that can provide evidence that they work in a low
risk environment and can demonstrate that seeking an ACD from patients is inappropriate in
their care setting, will fully meet Actions 1.18.4, 9.8.1 and 9.8.2 where they comply with
these requirements.
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