Advance Care Planning and End of Life Care Newsletter - December 2016 as PDFWelcome to the quarterly Advance Care Planning and End of Life Newsletter, which is jointly published by the Agency for Clinical Innovation (ACI), Clinical Excellence Commission (CEC) and the NSW Ministry of Health.

The newsletter provides updates on ACI, CEC and Ministry Advance Care Planning and End of Life projects and a guest spot for a local health district (LHD), specialty health network (SHN) or pillar to provide information on their initiatives. If you would like to showcase a local initiative in the 2017 newsletters please email:

In this edition

Update: End of life care initiatives at the Agency for Clinical Innovation

Care for people who are approaching and reaching the end of life occurs in many settings and is the responsibility of a wide range of healthcare providers. This is reflected in the breadth of initiatives across the clinical networks, taskforces and institutes at the ACI that aim to support improvements in such care.

The Palliative Care Network’s Palliative and End of Life Care Blueprint for Improvement is designed to provide the architecture that can support services to construct their own, localised models of care based on their local priorities. It aims to address a ‘wicked’ problem by mapping out a system transformation journey; providing the resources and knowledge to LHDs for them to develop their own system improvements.

The Palliative Care Network is in the early stages of planning an initiative which aims to facilitate analyses of local needs and priorities in partnership with local health districts, primary and aged care sectors. The Network has been pleased to learn that a number health services have already used the Blueprint to inform local models of care, palliative and end of life care plans and service reviews.

Five ACI clinical networks (Palliative Care Network, Respiratory Network, Rehabilitation Network, Chronic Care Network, and Transition Network) are collaborating on an initiative that aims to improve care for people with neurodegenerative and neuromuscular conditions. This will include consideration of end-of-life care needs in this patient population. A Governance Group has been assembled to oversee this work and the group’s inaugural meeting was held in early November.

The Rehabilitation for Chronic Conditions Framework has been developed to support a uniform approach to rehabilitation for people with chronic conditions, specifically where a person is ageing with multimorbidity. It recognises the importance of advance care planning and involves phased conversations throughout the person’s journey.

The Emergency Care Institute (ECI) has partnered with the UNSW CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) investigators to conduct a research project to validate a screening tool to identify elderly people who may be likely to die when they present to Emergency Departments, estimate their risk of death and refer them to appropriate services.

All of these initiatives contribute the ACI’s vision of all people in NSW having access to quality care based on assessed need as they approach and reach the end of life.

More information

For more information contact:
Nick Goryl, A/Palliative Care Network Manager
Phone: (02) 9464 4675

Clinical Excellence Commission's project update

The End of Life program aims to support provision of safe, quality end of life care in NSW public health organisations.

Admitted patient death screening

The admitted patient death screening tool includes indicators on the quality of dying. LHDs & facilities have over 18 months of screening data available to interpret, to assist them with identifying themes about how patients die in their service and how the data can be used for improvement.

'Last Days of Life’ Toolkit

The toolkit aims to provide non-palliative clinicians with the tools and resources to care for dying patients. It is currently being piloted in 20 facilities across 10 LHDs. To date there has been a positive response, from both medical and nursing staff, in relation to the value of the tools. The pilot will finish in December 2016 and evaluation report will be released in early 2017.

AMBER care bundle

The program provides the means for clinicians to discuss and develop an end of life plan with the patient and family/carers alongside an active management plan.

The AMBER care bundle has been included in the eMR2 Advance Care Plan package. The eMR2 Advance Care Plan package is currently being tested and should be released in early 2017.

More information

For more information contact CEC End of Life Program
Phone: (02) 9269 5596

NSW Ministry of Health update

Advance Care Planning and End-of-Life Care- Learning Pathway

The Ministry has finalised the Advance Care Planning and End-of-life Care - Learning Pathway and Resources for publication.

The resources are designed to inform and assist LHDs and SHNs with planning and delivery of education in advance care planning and end of life care.

The resources have been developed by the Ministry of Health, ACI, CEC and the Health Education and Training Institute (HETI) to prepare and support clinicians in having an empathic conversation or series of conversations.

The resources are available to all NSW Health staff through HETI online.

Advance Care Planning- Making your wishes known brochure

The Ministry recently updated its ‘Advance Care Planning – Making your wishes known’ brochure. The brochure introduces the topic of advance care planning to patients, their families and carers. The brochure is now available in ten community languages.

The Ministry has also developed a similar brochure for health professionals ‘Advance care planning – helping your patients to make their wishes known’.

More information

For more information contact
Phone: (02) 9391 9110

2016 National Advance Care Planning Conference Update

The 2016 National Advance Care Planning Conference was held in Melbourne on 15 to 17 November 2016.

One of the projects discussed at the conference was the Advance project. The Advance project is a free toolkit for registered and enrolled nurses who are currently working in general practice.

The toolkit consists of screening and assessment tools and a training package, specifically designed to support nurses in general practice to enable earlier advance care planning. It will also assist with enabling efficient use of support services and appropriate and timely referrals to specialist palliative care services as required.

More information

For more information on Advance visit the webpage.

The ACI, CEC and the Ministry of Health would like to wish everyone all the best for the festive season

Current as at: Friday 9 August 2019
Contact page owner: Health and Social Policy