By Dr Kanwal Singh, GP, Burslem Medical Centre, Maddington
Embedding advance care planning (ACP) in the general practice setting facilitates the integration of proactive ACP discussions, which, in turn, enable earlier, values-based conversations, improve alignment of care with patient goals and reduce family stress during acute episodes.
Supported by the Greater Choices for At Home Palliative Care lead at WA Primary Health Alliance, we took part in the Palliative Care Champions initiative last year which has greatly improved staff skills and confidence in ACP and early palliative care identification through education and mentoring. It is now standard practice at our surgery, with staff and patients feeling better supported than before.
Changes in Practice
We nominated our Practice Manager Shikha Panag as our Palliative Care Champion and initiated regular practice meetings which doctors lead to identify how best to embed ACP in our practice and bring the whole team on the journey, as we embraced this new approach.
Twelve months on, witnessing firsthand the tangible benefits for both staff and patients has been transformative. Overall, the project has strengthened our practice’s capacity to provide timely, coordinated, and patient-centred palliative care.
By integrating ACP discussions into routine appointments, health assessments (75+ and Indigenous Health Assessments) and chronic condition management plans, we now provide more personalised care. We are trialling the Supportive Care model developed by WAPHA, involving consistent use of Primary Sense* reports and two palliative care assessment tools.
Positive Impact on Outcomes
- Proactive Management: We reviewed Primary Sense reports to identify our patients with complex needs and who may be at risk of dying within 12 months. We then adopted two palliative care evidence-based tools – the Australian Karnofsky Performance Scale (AKPS) and the Symptom Assessment Score (SAS) – as part of our assessment process. These tools allow us to proactively manage care in the setting of expected deterioration and trigger referrals to appropriate community and specialist services. The aim is to reduce crisis presentations to the emergency department and support choice for patients to remain at home for as long as possible, or to die there if that is their preference.
- Expanded Nursing Scope: Our nurses are now actively involved in ACP delivery, conducting SAS/AKPS assessments, and developing GPMPs, thus enhancing team capacity and coordination of care.
- Team Education and Mentoring: Ongoing education through the Greater Choice program has improved staff confidence and capability in recognising palliative needs and managing complex symptoms. Post-project learning needs analysis surveys showed a significant uplift in skills.
- Proactive Follow-Up: Clinical flags (e.g. frailty, frequent admissions, advanced chronic disease) enable proactive identification and follow-up of high-risk patients. Regular contact and early interventions have helped more patients to remain at home and reduced avoidable hospital presentations.
- Improved Coordination of Care: Participation in the Palliative Care Champions project has meaningfully improved coordination of care within our clinic and across services. The program enhanced our team’s awareness and understanding of advance health directives, which in turn strengthened communication between clinicians, patients and external providers.
Case study:
A patient with advanced COPD took part in an ACP discussion with their GP at our practice and the clinic’s Palliative Care Champion, clearly expressing their wish to remain at home and avoid hospital admission at the end of life. When their health declined, the ACP documentation enabled all providers to respect these wishes. The community palliative care team supported the patient to stay at home, where they died peacefully with family present. This case study demonstrates how early ACP conversations and co-ordinated care can honour patient preferences and support their families.
- Influence on Quality Improvement: The practice integrated ACP into routine workflows, leading to earlier and more frequent ACP discussions. High-complexity patients are now proactively identified and prioritised, ensuring timely care and allowing many to remain at home in line with their preferences. The project also enhanced the practice’s quality improvement (QI) culture, with better documentation, data tracking and increased staff engagement.
- Embedded After Death Audit Process: The after-death audit process involved a multidisciplinary review of all patient deaths over the past 6–12 months, focusing on the presence of ACP, place of death, involvement of palliative services and whether preferences were honoured. Reflective meetings allowed us to analyse findings and identify areas for improvement, revealing that early ACP discussions increased the likelihood of patients dying in their preferred setting. As a result, we embedded ACP prompts into chronic disease management, and regular after – death reviews have become a standard part of our practice’s quality improvement efforts. Adoption of this audit as part of our QI process has had many benefits, including CPD for Educational Activity, Reflective Practice and Measuring Outcomes which has been popular with our team.
Lessons Learned
Initially, we encountered hesitancy due to a lack of confidence among our staff about initiating end-of-life conversations. We overcome this through regular training, open dialogue and a collaborative approach involving all team members who have wholeheartedly embraced this new way of working and are seeing the tangible benefits for our patients and their families as they navigate end of life.
The practice now maintains ACP as a routine component of care, supported by ongoing team education, mentoring and systematic after-death audits to continually refine end-of-life practices.
*Primary Sense is a clinical decision support tool fully subsidised by WAPHA for general practices in Western Australia that share their de-identified, full population health data set).
Originally published in Medical Forum (account required for access).