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Who’s My Voice?

South Eastern Sydney Local Health District
Project Added:
30 November 2015
Last updated:
3 December 2015

Who’s My Voice?


This project worked in collaboration with residential aged care facilities (RACFs) to assess current practices and develop a robust, sustainable and transferable process to deliver Advanced Care Planning (ACP) in RACFs.

View a poster from the Centre for Healthcare Redesign graduation, December 2015.

Who’s My Voice? poster


To increase the uptake of ACP in RACFs.


  • Reduces stress and uncertainty for patients, families and staff in RACFs and hospitals.
  • Allows residents to be treated in the RACF.
  • Reduces unnecessary emergency department transfers and admissions.
  • Increases patient safety, due to a reduced number of transfers to hospital.
  • Streamlines care processes for RACFs.
  • Increases patient, family and RACF staff satisfaction.
  • Ensures that residents’ wishes are followed.
  • Reduces family conflict when residents experience clinical deterioration.

Project Status

Key dates

  • Project start: February 2015
  • Project finish: December 2015


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


The projected rise in the ageing population, the rise in dementia and chronic diseases and the significant number of people dying in acute care facilities over the next 20 years suggest the current approach to end of life care will become inadequate in meeting the community’s needs over the next decade.

It is a responsibility of the health system to ensure patients’ end of life wishes are respected and that quality, timely and appropriate care is provided to dying patients. 

ACP is a means of improving end of life care and allows a person’s wishes to be known before they lose their decision-making capacity. It includes a cognitive person completing an advance care directive and appointing an enduring guardian. If the resident is incognitive, the carer must complete an advance care plan on behalf of the resident.

Through comprehensive needs assessments, Central and Eastern Sydney Primary Health Network and SESLHD found that less than 10% of RACF residents in the St George and Sutherland Shire had ACP in place. This resulted in avoidable presentations to hospitals, as well as clinical interventions that were not aligned to the resident’s wishes.

Project case for change, with quote from resident and statistics


Policies and procedures

  • Developed standard procedure on admission that ensures all residents are familiar with ACP and receive support when completing the ACP forms.
  • Standardised ACP forms within the RACF, from the NSW Advance Care Directive Association.
  • Displayed reporting of ‘percentage of residents with ACP’ on the front page of the RACFs' clinical audit tool.

Education and training

  • Delivered training on ACP to residents, carers and RACF staff.
  • Provided experienced palliative care nurses as mentors to RACF staff as they upskill.
  • Engaged general practitioners and nurses to educate them on the benefits of ACP.


  • Developed brochures and posters to support communication.
  • Ensured each case conference included the resident, carer, RACF staff and general practitioner.
  • Provided material and case conferencing in the residents’ preferred language.
  • Maintained respect for cultural beliefs regarding end of life wishes.

Implementation sites

  • Blakehurst Aged Care Centre
  • The Laurels Hostel
  • Percy Miles Villa Aged Care 


  • Blakehurst Aged Care Centre
  • The Laurels Hostel
  • Percy Miles Villa Aged Care
  • Garrawarra Aged Care Centre
  • Anne Meller, Palliative Care Clinical Nurse Consultant, Prince of Wales Hospital
  • Dr Joel Rhee, General Practitioner, University of NSW
  • Dr Roslyn Ridgeway, General Practitioner
  • Central and Eastern Sydney Primary Health Network


  • The project team is currently in the evaluation phase of the project. The tools used to evaluate the success of the project include:
    • patient experience trackers
    • resident interviews
    • carer interviews
    • staff interviews
    • data review
    • policy and process review.
  • Participating RACFs have implemented a standardised form and process for completing the ACP forms.
  • Each RACF is reporting on the 'percentage of residents with ACP' on their quality audit tool, with results currently undergoing assessment.
  • Training has been provided to the staff at all 63 RACFs within the St George and Sutherland Shire area.
  • ACP brochures and posters have been developed and distributed to all 63 RACFs within the region and are available in other languages.
  • Case conferencing training programs have been set up with a palliative care clinical nurse coordinator for the three selected RACFs.

Lessons Learnt

  • Cultural and religious beliefs are a barrier to the completion of ACP forms.
  • Having an ACP is just the first step, the next important step is to ensure it is adhered to by general practitioners and hospitals.
  • Some solutions may be ideal but not possible, due to the high level of governance required.

Project Team

  • Jessica Harris
  • Olive Levi
  • Jennifer Pollock
  • Kimberley Thomsett


Kimberley Thomsett
Stream Manager, Aged Care and Rehabilitation
South Eastern Sydney Local Health District
02 9947 9866

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