How New Zealand's Advance Care Planning System Works

New Zealand has developed one of the world's most cohesive and well-structured advance care planning (ACP) systems, offering valuable insights for individuals and healthcare providers around the globe. As an advance care planning specialist who has studied international approaches, I've found New Zealand's nationally coordinated yet locally flexible system particularly noteworthy for its integration with everyday healthcare and cultural responsiveness.

The Foundation: A National Framework with Local Implementation

Unlike many countries where advance care planning developed through fragmented regional initiatives, New Zealand established a coordinated national approach while maintaining flexibility for local adaptation.

National Coordination

The Health Quality & Safety Commission New Zealand leads the country's advance care planning programme, providing consistent guidance, resources, and implementation support across all health districts. This national coordination creates several distinct advantages:

• Standardised training for healthcare providers
• Consistent documentation formats
• Coordinated public awareness campaigns
• Unified electronic storage systems
• Regular quality improvement initiatives

This national framework ensures that advance care planning documents created anywhere in New Zealand will be recognised and honoured throughout the country's healthcare system.

Local Flexibility

Within this national structure, District Health Boards adapt implementation to meet local needs, particularly regarding cultural responsiveness and community engagement. This balanced approach combines standardisation, where beneficial with customisation where necessary.

Research published in the New Zealand Medical Journal highlights how this flexible implementation has allowed regions with higher Māori and Pacific populations to develop culturally specific approaches while maintaining consistency with national standards.

Key Elements of the New Zealand System

New Zealand's advance care planning system incorporates several distinctive features that contribute to its effectiveness:

Person-Centred, Values-Based Approach

Rather than focusing primarily on specific medical interventions, New Zealand emphasises articulating the values and beliefs that should guide healthcare decisions. The widely-used My Advance Care Plan document begins with questions about what matters most to the individual before addressing specific treatment preferences.

This values-based foundation helps healthcare providers interpret advance care plans in unexpected situations not specifically addressed in the documentation. It also makes advance care planning more accessible to individuals without detailed medical knowledge.

Integration with Primary Healthcare

New Zealand has successfully embedded advance care planning within routine primary care, rather than treating it as a separate specialised service. General practitioners and practice nurses receive specific training in facilitating these conversations during regular consultations.

The Royal New Zealand College of General Practitioners has been instrumental in promoting this integration, emphasising advance care planning as an essential component of comprehensive primary care rather than a standalone initiative.

Electronic Accessibility Through Shared Care Records

One of New Zealand's most significant innovations has been the integration of advance care plans into electronic shared care records. This system ensures that advance care planning documents are immediately accessible to emergency departments, after-hours providers, and specialists regardless of where they were created.

The Health Information Standards Organisation has developed specific standards for electronic advance care plans, addressing persistent accessibility challenges that many other countries continue to face.

Cultural Responsiveness: The Māori Approach

New Zealand's approach to advance care planning demonstrates exceptional cultural responsiveness, particularly regarding Māori perspectives on health, dying, and decision-making. Rather than imposing Western individualistic models, the system accommodates Māori concepts like:

• Whānau (extended family) involvement in healthcare decisions
• Tikanga (customs) surrounding illness and end-of-life care
• Kanohi ki te kanohi (face-to-face communication) for sensitive discussions
• Wairua (spiritual dimensions) of healthcare and dying

The Advance Care Planning Cooperative has developed Māori-specific resources that reflect these cultural values while maintaining compatibility with the national framework.

The Legal Status of Advance Care Plans in New Zealand

New Zealand takes a distinctive approach to the legal status of advance care planning documents compared to many other jurisdictions.

Common Law Recognition

Unlike countries with specific advance directive legislation, New Zealand's advance care plans derive their authority primarily from common law principles. The Code of Health and Disability Services Consumers' Rights (particularly Right 7(5)) provides the legal foundation for respecting advance directives.

This common law approach offers greater flexibility than highly prescriptive statutory frameworks, allowing advance care planning to evolve through practice rather than requiring legislative changes.

Focus on Process Over Documentation

New Zealand emphasises the advance care planning conversation and process rather than focusing narrowly on producing legally binding documents. This approach recognises that even without formal documentation, well-documented discussions in medical records provide valuable guidance for healthcare decisions.

Research demonstrates that this process-focused approach leads to higher completion rates and better alignment between patient preferences and actual care received.

Implementation Through a Collaborative Model

New Zealand's success with advance care planning largely stems from its collaborative implementation model involving multiple stakeholders:

The Advance Care Planning Cooperative

At the centre of implementation sits the Advance Care Planning Cooperative, a multidisciplinary network of healthcare professionals, researchers, policy makers, and consumer representatives who guide the national programme's development.

This cooperative structure ensures that advance care planning initiatives reflect diverse perspectives and remain responsive to emerging needs and challenges.

Staged Implementation Approach

Rather than attempting immediate nationwide implementation, New Zealand adopted a phased approach:

1. Initial pilot projects in selected regions
2. Evaluation and refinement of processes
3. Development of standardised training and resources
4. Gradual expansion with continuous improvement
5. Integration with electronic health records

This methodical expansion has allowed the system to mature organically while building capacity and addressing implementation challenges.

Comprehensive Training Programmes

New Zealand has invested heavily in advance care planning education for healthcare providers through a tiered training programme:

• Level 1: Basic awareness for all healthcare workers
• Level 2: Skills-based training for those regularly involved in discussions
• Level 3: Advanced facilitation training for practitioners leading implementation

This structured approach ensures consistent quality while building system-wide capability. The Health Quality & Safety Commission provides these training resources nationally.

Measuring Success: Outcomes and Ongoing Challenges

New Zealand's systematic approach allows for ongoing evaluation and quality improvement:

Measurable Outcomes

Recent evaluation studies demonstrate several positive outcomes:

• Increasing completion rates across all age groups
• Greater alignment between documented preferences and care received
• Reduced decision-making burden on families during crises
• High satisfaction from both patients and healthcare providers
• Decreasing unwanted hospital admissions near end-of-life

Ongoing Challenges

Despite its successes, New Zealand continues addressing several challenges that offer learning opportunities for other systems:

• Ensuring equity of access across different population groups
• Maintaining quality during rapid system expansion
• Balancing standardisation with personalisation
• Developing appropriate approaches for younger adults
• Managing the transition between planning documents and clinical orders

The Evaheld platform addresses similar challenges through user-friendly interfaces and secure accessibility features.

Lessons From the New Zealand Model

Several key lessons emerge from New Zealand's approach that could benefit advance care planning systems elsewhere:

1. National coordination with local flexibility creates an effective balance between standardisation and customisation.
2. Cultural responsiveness should be built into core processes rather than added as an afterthought.
3. Integration with primary care normalises advance care planning as part of routine healthcare.
4. Values-based approaches provide better guidance than exclusively treatment-focused directives.
5. Electronic accessibility solves persistent challenges with document availability during emergencies.



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Conclusion

New Zealand's advance care planning system offers a compelling model for how national coordination, cultural responsiveness, and digital integration can create more effective approaches to documenting and honouring healthcare preferences. Its success demonstrates the value of systematic implementation focused on ongoing conversation rather than one-time documentation.

While every healthcare system has unique characteristics, the principles underlying New Zealand's approach—person-centredness, cultural responsiveness, accessibility, and integration with routine care—have universal relevance for anyone seeking to improve advance care planning processes.

For individuals interested in documenting their healthcare preferences with similar clarity and accessibility, Evaheld offers digital advance care planning solutions inspired by international best practices, including many elements that have proven successful in the New Zealand context.