Practical advance care planning for hospitalists

Advance care planning is often presented as a form-filling exercise, yet its value at admission is immediate: preferences shape resuscitation, treatment, transfer and discharge decisions. The practical legacy of Hospitalists and Advance Care Planning: Conversation Scripts from HM17 is to treat planning as a clinical conversation rather than paperwork. Hospitalists can connect a patient's goals with what the ward can realistically offer, then make those goals visible to the wider team. Learn more about Managing Acute Kidney Injury In The General Ward Updated Criteria From The Meeting.

These conversations gain meaning when adapted to Australian hospitals, where public and private services, interpreters, aged care providers and state-based laws all shape decision-making. A useful script does not dictate what a patient should choose; it creates enough space for values, trade-offs and uncertainty to be discussed and recorded clearly.

Why planning conversations stall at the bedside

Acute admissions compress planning into a narrow window. Delirium, pain, sedation or a sudden physiological change may leave a patient temporarily unable to participate, while anxious relatives focus on the next procedure rather than broader goals. Waiting until a crisis often reduces the discussion to resuscitation, allowing an urgent order to displace the person's actual preferences. A script restores perspective by asking what the patient values before teams present medical options.

Hospital Medicine 2017 brought hospitalists together at Mandalay Bay in Las Vegas to discuss research, practice and innovation. The conference program and resources offer context for treating communication as a clinical skill rather than a documentary task. Rehearsing openings, noticing whose goals are being voiced and recording agreements in language the whole team can use makes planning safer than relying on individual memory.

A short comparison shows how a narrow question can be replaced with a values-based opening:

Turn values into treatment boundaries

Goals are broader than treatment choices. A patient may prioritise remaining at home, attending a family event, preserving alertness or avoiding a particular intervention. Treatment boundaries connect those priorities to plausible clinical scenarios, such as ICU admission, ventilation or surgery. The script should first establish what matters, then explain the consequences of relevant options in plain language. Without that sequence, a technically correct discussion can feel like a request for consent rather than shared decision-making.

Australian law is state and territory based, so clinicians must check local rules for advance care directives, enduring powers of attorney and substitute decision-makers. A patient with decision-making capacity must be supported to make their own decision; family members can offer evidence of wishes but do not gain authority to override them. If capacity is absent, a valid directive or authorised substitute decision-maker becomes relevant, with substituted judgement and best interests guiding the process.

A directive should not be treated as a blanket refusal of beneficial care. It must be interpreted alongside current clinical information, including whether an illness is reversible and whether the stated outcome still applies. Document the goals, likely scenarios, agreed limits, decision-making arrangements and a review point. Where CPR status changes, translate the decision into the ward's current clinical orders so that the next shift is not left guessing.

Use a script that invites decisions

A useful script is brief enough for a busy ward and structured enough to prevent missed questions. It can move through permission, priorities, clinical meaning, shared understanding and documentation without sounding formulaic. The wording should feel like an invitation to think aloud, especially when the patient is tired, frightened or being asked to consider unfamiliar outcomes.

Openers for a brief ward conversation

• “Would it be useful if I explain what may happen if the illness worsens?”
• “What matters most to you during this admission?”
• “Who would you want involved if you could no longer speak for yourself?”
• “How much information would help you decide, and in what form?”

Close with a shared summary

• “What I hear is that your main priority is to remain at home with support.”
• “If your condition changes, which treatments would you want considered or avoided?”
• “Does this summary accurately reflect your wishes and the limits we discussed?”
• “I will document this, share it with the team and revisit it at the next review.”

After the conversation, ask the patient to explain the plan back in their own words; this tests whether explanations were clear rather than testing their memory. Use a professional interpreter, not a relative, whenever accuracy depends on language. Give the patient a copy of the summary and, with consent, send it to the GP and relevant aged care team, while making the next review visible. A concise record that captures the patient's reasoning is usually more useful than a long checklist full of completed boxes.

Adapt the conversation to Australian wards

In Melbourne and Sydney tertiary hospitals, patients may move between emergency, medical and surgical teams during one admission. Families are commonly contacted by mobile phone for updates, yet important decisions still need to reach the electronic record and bedside nurses. Interpreters and support people should be arranged early, including after hours, because a phone relative is not a substitute for supported decision-making.

In rural and remote services, the nearest suitable treatment may require transfer, making the consequences of postponement harder to explain. Telehealth can connect the patient, family and specialist team, but distance should shape the plan rather than justify assuming consent. In Aboriginal and Torres Strait Islander care, cultural safety starts with asking how the patient wants decisions made and who should be present, then using liaison and community support services where available.

The conference archive's review of updated AKI criteria is a useful ward reminder that severity and treatment response can change rapidly. Goals should shape how choices are made, not replace clinical reassessment or turn a potentially reversible problem into a fixed prognosis. For example, a patient who values independent living may still want dialysis trialed if that is consistent with their goals, while another may prioritise avoiding invasive treatment at any cost.

Australia's health market includes Medicare, public hospitals, home-care packages and residential aged care, so a discharge plan may involve several organisations. Confirm who holds an existing plan, ask the facility what support it can provide and verify any substitute decision-making authority under the relevant state law. Because requirements differ across jurisdictions, an interstate admission warrants checking the document rather than assuming it settles every current decision.

Carry the plan beyond the ward

A plan that remains in a bedside folder has not travelled with the patient. The discharge summary should identify the goals, the clinical scenario discussed, agreed limits, the decision-maker if one is needed, current CPR status and the date the plan should be reviewed. Keep it readable and avoid jargon, because it will be used by GPs, ward nurses, ambulance crews and aged care staff.

Hospitalists can add coherence by explaining why a treatment fits the patient's goals, not merely recording it. With consent, share the summary with the senior clinician, specialist palliative care team if appropriate, GP and community providers, and name a clinician responsible for the next review. This prevents one specialty from treating a general goal as if it were a specialty-specific instruction.

The practical takeaway is to prepare one patient, one short script and one shared plan before leaving the next ward round; that small habit turns good intentions into treatment decisions the patient can still recognise and endorse.