Establish the goals and needs of the person, their family and carers to ensure the person’s preferences and needs are reflected
Care planning establishes the care goals and needs of the person, their family and carers. Individuals should be involved as much as possible in their care planning, to ensure their preferences and needs are reflected. Recognising variation in community and cultural preferences and expectations of care will help to support a person-centred approach for all. Multicultural health and Aboriginal health professionals can provide cultural guidance and support and, where applicable, be part of the multidisciplinary team.
Processes are in place to ensure that following comprehensive assessment of people with life-limiting illnesses, the person, their family and carers are actively involved in discussions and decisions regarding immediate care needs and advance care planning.
Appropriate documentation must reflect these decisions.
Care planning is important to support meeting the goals and needs of the person with life-limiting illness, their family and carers.
Advance care plans must be readily available for current and future care providers, including during unplanned and out-of-hours care (including formal documents, such as advance care directives).
Advance care planning information and resources are available on the NSW Health website and tools such as the End of Life electronic medical record (eMR) solution can improve shared care planning across multiple settings.
Care plans need to be communicated with the person’s general practitioner and original referrer.
Processes must be in place to ensure periodic reassessment of patient and family/carer needs, as these needs may change over time. This includes the provision of relevant health literate information.
Questions family members or carers may want to ask when their relative or friend’s condition deteriorates, or a decision is made to initiate a palliative approach to care.
Clinical Excellence Commission | Information | 2016
Questions a patient may ask when they deteriorate, or a decision is made that there are no reversible causes of deterioration.
Clinical Excellence Commission | Information | 2016
Cloud-based document for people in their last year of life for sharing information.
Hunter New England Local Health District | Information | 2021
The peak body and leading voice in NSW promoting quality palliative care for all.
Palliative Care New South Wales | Information | 2021
Evidence-based information to support best practice palliative care, for health professionals.
Australian Department of Health | Information | 2021
Encourages people of all ages and health status to talk about death and dying.
Palliative Care Australia | Information | 2021
Dying Well: Improving palliative and end of life care for people with dementia
Discussion paper which examines the state of end of life and palliative care for people with dementia and their families.
Dementia Australia, Victoria | Information | 2019
Provides online learning opportunities and practice resources for doctors, nurses and allied health professionals to improve the quality and safety of end-of-life care in hospitals.
Flinders University | Educational | 2021
Assists in the recognition of the dying patient and development of individualised management plans.
Clinical Excellence Commission | Information | 2017
NSW Paediatric Palliative Care Programme
Provides information for patients, families and health professionals who care for a child with a life-limiting illness.
Sydney Children's Hospital Network | Toolkit | 2021
The palliative care evidence and practice information resource for the Australian aged care sector.
Flinders University | Information | 2021
A systematic approach for the multidisciplinary team to follow when clinicians are uncertain whether a patient may recover.
Clinical Excellence Commission | Toolkit | 2020
Using Resuscitation Plans in End of Life Decisions
Standards and principles relating to appropriate use of resuscitation plans by NSW public health organisations for patients 29 days and older.
NSW Ministry of Health | Clinical tool | 2014
Resource for NSW patients, families, carers and health professionals to get information on advance care planning.
NSW Ministry of Health | Information | 2020
Advance Care Planning: Information for health professionals
Information for NSW health professionals on advance care planning.
NSW Ministry of Health | Educational | 2020
Advance Care Planning Australia
A national program which enables Australians to make the best choices for their future health and care.
Austin Health | Information | 2020
Advance Care Planning: Making your wishes known
Advance care planning information brochure available in multiple languages.
NSW Multicultural Health Communication Service | Information | 2017
Dignity, Respect and Choice: Advance Care Planning for End of Life for People with Mental Illness
Support people with mental illness with complex issues around advance care planning.
NSW Ministry of Health | Toolkit | 2015
Making an Advance Care Directive
Information to help people complete an advance care directive
NSW Ministry of Health | Information | 2019
A digital platform for storing personal health information, which can be accessed by patients and authorised health professionals.
Australian Digital Health Agency | Clinical tool | 2021
NSW Ambulance Authorised Care Plans
Enable paramedics to provide individualised care to patients who have a life limiting illness, in their home or in a residential aged care facility.
NSW Ambulance | Clinical tool | 2019
Practical caring involves undertaking a coordinated assessment as part of end of life care.
Dawn Hooper Clinical Nurse Consultant, Palliative Care, Northern Sydney Local Health District
Community palliative care teams
The role community palliative care has in caring for people and in supporting people who wish to die at home.
Trish Sutton Clinical Nurse Consultant, Palliative Care Cancer and Haematology Services, Prince of Wales Hospital and Community Health Service
Sandra Sullivan Clinical Nurse Consultant, Community Palliative Care, Bankstown Community Health Centre
Motor neurone disease in aged care
Jo Fowler covers what motor neurone disease is, the types, incidence and prevalence, along with common signs, symptoms and management.
Jo Fowler Retired MND NSW Regional Advisor – Central Coast, MND Association NSW
The benefits and challenges involved in delivering rural and remote palliative care services.
Dr Sarah Wenham Senior Staff Specialist - Palliative Care, Clinical Director - Sub and Non-Acute Care, Far West Local Health District