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Plan Early: My Future Care

Project Added:
16 August 2016
Last updated:
21 April 2021

Plan Early: My Future Care


This project delivers advance care planning to patients with end-stage chronic lung disease, by implementing staff training, standardising work practices for Advance Care Plan (ACP) documentation, engaging general practitioners (GPs) and using an evidence-based tool that predicts the risk of death within 12 months.

View a poster from the Centre for Healthcare Redesign graduation, August 2016.

Plan early poster


To identify which Respiratory Coordinated Care Program (RCCP) patients require an ACP by December 2016 and ensure 65% of all RCCP patients with end-stage chronic lung disease have a completed ACP by June 2017.


  • Enhances patient-centred care by appropriately involving patients in end of life care planning in a timely way.
  • Improves documentation of medical interventions for patients with end-stage chronic lung disease.
  • Aims to ensure ACPs are available at the point of care (e.g. emergency departments).
  • Provides clinicians with evidence-based tools to predict survival rates of patients with end-stage chronic lung disease.
  • Reduces stress and anxiety for patients with advanced progressive respiratory illness and their carers, by reducing the occurrence of inappropriate or unwanted treatment in hospital.
  • Reduces hospital admissions, readmissions and length of stay.
  • Improves the ability of staff to meet the advance care planning needs of their patient and the confidence to initiate discussions about end of life care and completing an ACP.


The RCCP at Prince of Wales Hospital is a respiratory physician-supported outreach service that provides multidisciplinary support to patients with chronic lung disease. The aim of the program is to improve the quality of care provided to patients, while reducing hospital admissions, readmissions and length of stay.

Prior to the project, none of the 250 RCCP patients at Prince of Wales Hospital had an ACP that was accessible by their clinician. The ACP had either not been completed, or it was completed but not available at the point of care. There was no systematised way of accessing or accepting a patient’s ACP, or knowing they had one. Respiratory staff had no training on how to engage with patients about planning for future care.

For the purposes of this project, advance care planning is considered a process, or a series of conversations about future care. The project therefore takes a broad view of documents relevant to advance care planning, to include an Advance Care Directive, NSW Ambulance Authorised Adult Palliative Care Plan and NSW Health Adult Resuscitation Plan. The availability of this information at the place a person is receiving medical or paramedical care is critical to ensuring people receive the right care at the right time and in the right setting.

Prior to the project, there was no standard process to identify which RCCP patients needed an ACP, or way to prompt clinicians to consider starting advance care planning with an individual patient. In a survey of RCCP patients and carers conducted in September 2015, 67% of carers stated that end of life care was discussed with the patient less than five months before their death. Research suggests that limits on medical intervention are often not discussed until around 48-72 hours before the patient dies. Both patients and carers suggested that the timing and quality of the discussions about end of life care could be improved.

A survey of RCCP nurses and respiratory doctors conducted in October 2015 found that 80% did not think enough patients had ACPs. All non-medical staff surveyed said they did not feel confident in meeting the palliative care needs of their patient.


  • The Hospital-patient One-year Mortality Risk (HOMR) tool was implemented in the RCCP program, to identify patients who have a 40-90% chance of dying within 12 months. These patients were ranked in order of HOMR score, so doctors could identify which patients required more urgent end of life care discussions.
  • Face-to-face training was provided to RCCP nurses by the advance care planning clinical nurse consultant over two sessions, to improve the confidence of staff when initiating and completing an ACP.
  • Current eMR alerts will be used, so all hospital staff know when a patient has an ACP and can access the details of this plan. Members of the project team are also involved in eHealth consultation regarding eMR2 resuscitation order and eMR alerts. Work is currently underway on these functions and is expected to be completed by December 2016.
  • A communication strategy is currently underway, to provide RCCP staff with a simple way to share ACPs with the patient’s GP.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • Project start: 19 August 2015
  • First Advance Care Plan (ACP) completed: 16 June 2016
  • Phase one complete: 31 December 2016
  • Phase two complete: 30 June 2017

Implementation site

  • Department of Respiratory and Sleep Medicine, Prince of Wales Hospital, SESLHD.



  • As of August 2016, 16% of end-stage RCCP patients had resuscitation plans (up from 0%).
  • An initial evaluation will take place in December 2016, to measure compliance with the HOMR tool and its success in identifying patients who require an ACP.
  • These results will also determine its suitability for providing clinicians with accurate survival rates of palliative care patients across SESLHD.
  • A full evaluation will take place in June 2017, to measure:
    • the type and number of ACPs documented
    • the number of advance care planning discussions held
    • feedback from patients and carers prior to and following advance care planning discussions
    • feedback from staff on their confidence levels prior to and following advance care planning training.

Lessons learnt

  • ACPs must be available at the point of care, every time.
  • There is no single advance care planning document that is suitable for all patients – Advance Care Directives, NSW Ambulance Authorised Adult Palliative Care Plans and Resuscitation Plans each have different advantages. It helps to have an ACP expert on your project team, such as an advance care planning clinical nurse consultant.
  • Patients, carers and staff are change ready and wish to engage with and support advance care planning.
  • Technology barriers are significant and rely on consultation from NSW Health.
  • The approach has received positive feedback from GPs and will be further tested during implementation.


NSW Ambulance. Authorised Adult Palliative Care Plan. Sydney Local Health District.

Further reading


Louise Deady
Clinical Redesign Officer
South Eastern Sydney Local Health District
Phone: 02 9947 9803

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