Advance care planning

Improving end-of-life care for residential aged care residents

The partnership between Brisbane South PHN and Metro South Hospital and Health Service continues in a three phase pilot project to embed sustainability of quality patient centred end-of-life care in Residential Aged Care Facilities (RACFs) in the Brisbane South PHN area.

Phase One, the pilot project commenced in September 2016 with an aim of improving end-of-life care for residential aged care residents in the Brisbane South PHN catchment area by supporting RACFs in embedding an evidence-based Advance Care Planning program into routine care. The pilot incorporated:

  • education about Advance Care Planning for nominated RACF nurse champions
  • GP education for those who attend the RACFs
  • information sheets for residents, families/substitute decision makers
  • an exemplary Advance Care Planning policy and procedure to support the implementation of an Advance Care Planning program into routine care in an RACF.

Phase two commenced in July 2017, and focussed on best clinical practice at end-of-life care in RACFs through multiple strategies:

  1. offering the Advance Care Planning project to the remainder of the RACFs in Brisbane South PHN geographical area who had not participated in the first phase
  2. broadening the scope of the education by including the Residential Aged Care Palliative Approach Link Nurse project to increase the capacity of RACF staff to deliver comprehensive, evidence-based palliative approach to care within RACFs and to improve resident and family outcomes
  3. ongoing access to educational resources, ongoing promotion and support such as an end-of-life conference and blog.

The third phase of the project commenced in September 2018. Phase 3 focusses on embedding and sustaining quality end-of-life care using the End-of-Life Care Clinical Model (115kb pdf) aiming for improving resident, family and staff satisfaction with care and increased numbers of residents dying in their place of choice.

To view the information about the projects and the learning modules, as well as upcoming events please visit