ADV-POL-001: Advance care planning conversations

Policy · ADV-POL-001 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 49.1

At a glance

Patients with serious or progressive illness are offered a conversation about their future care.
The conversation takes place at a time and in a way that suits the patient, with an interpreter where needed (HMG-POL-003).
The patient’s wishes are recorded with the date, and shared with the care team where the patient agrees (ADV-FRM-001).
Wishes are reviewed when the patient’s condition changes.
Stop and get help straight away if: a patient with serious or progressive illness is never offered the conversation.

1. Purpose

To make sure patients with serious illness are offered the chance to talk about their future care, and that their wishes are recorded (49.1).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

A person living with serious illness may want to talk about what matters to them in future care. Being offered that conversation, at the right time, lets their wishes guide the care.

5. Responsibilities

Role	Responsibility	Competence
Treating clinician	Offers and holds the conversation	Clinical lead
Clinical lead	Keeps the list of patients who need the offer and checks it is made	Hospital director

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Identify.

Identify patients with serious or progressive illness from the clinical record.

Key point: Identified.

Step 2. Offer.

Offer the conversation at a time suited to the patient, and ask whether they want it now.

Key point: Offered.

Step 3. Record.

Record the patient’s wishes and the date (ADV-FRM-001), and share them where the patient agrees.

Key point: Recorded.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Eligible patients offered the conversation	100%	Quarterly	Clinical lead	Escalate to the hospital director
Wishes recorded for patients who accept	100%	Quarterly	Clinical lead	Repeat the offer

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
ADV-FRM-001	Record of patient wishes for future care	Record
HMG-POL-003	Interpreters and cultural mediators (existing, reused)	Policy

17. Evidence

Reference	Note
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Healthcare Ethics for ASF Accreditation (A-07)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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