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Background: Lack of access, late engagement and limited referral for palliative care remain critical issues in supporting Indigenous Australians with life limiting illness. Aim: To explore the experiences and perspectives of Indigenous and non-Indigenous health professionals regarding the provision of palliative care for Indigenous people with advanced disease. Design: Qualitative study involving semi-structured focus groups/interviews with analysis following an inductive thematic approach. Setting/participants: A purposive sample ( n = 54) of medical, nursing, allied health and Indigenous Hospital Liaison Officers engaged in caring for Indigenous patients at a metropolitan teaching hospital in Australia. Results: Four overarching themes were identified regarding provision of palliative care for Indigenous patients. These were (1) the intersection of cultures – Indigenous peoples, health and palliative care, (2) bridging the cultural divide: the integral role of Indigenous Hospital Liaison Officers, (3) health professionals devolve their responsibility to provide culturally appropriate care and (4) building towards a more holistic, culturally aware provision of palliative care. Conclusions: For many Indigenous people, the health system may be experienced as inflexible, narrowly focused and even prejudiced and traumatising. For Indigenous patients at the end of life, these challenges are heightened. The Indigenous Hospital Liaison Officers, working at the intersections of these two cultures, are key to negotiating such challenges as they seek opportunities to facilitate communication and understanding between firmly held cultural needs.

Background: Palliative care is an emerging scope of practice for paramedicine. The COVID-19 pandemic has highlighted the opportunity for emergency settings to deliver palliative and end-of-life care to patients wishing to avoid intensive life-sustaining treatment. However, a gap remains in understanding the scope and limitations of current ambulance services’ approach to palliative and end-of-life care. Aim: To examine the quality and content of existing Australian palliative paramedicine guidelines with a sample of guidelines from comparable Anglo-American ambulance services. Design: We appraised guideline quality using the AGREE II instrument and employed a collaborative qualitative approach to analyse the content of the guidelines. Data sources: Eight palliative care ambulance service clinical practice guidelines (five Australian; one New Zealand; one Canadian; one United Kingdom). Results: None of the guidelines were recommended by both appraisers for use based on the outcomes of all AGREE II evaluations. Scaled individual domain percentage scores varied across the guidelines: scope and purpose (8%–92%), stakeholder involvement (14%–53%), rigour of development (0%–20%), clarity of presentation (39%–92%), applicability (2%–38%) and editorial independence (0%–38%). Six themes were developed from the content analysis: (1) audience and approach; (2) communication is key; (3) assessing and managing symptoms; (4) looking beyond pharmaceuticals; (5) seeking support; and (6) care after death. Conclusions: It is important that ambulance services’ palliative and end-of-life care guidelines are evidence-based and fit for purpose. Future research should explore the experiences and perspectives of key palliative paramedicine stakeholders. Future guidelines should consider emerging evidence and be methodologically guided by AGREE II criteria.

Clinical trials are a key component of expanding the evidence base in palliative care. A key strategic objective of the Victorian Comprehensive Cancer Centre (VCCC), a multisite cancer center alliance, was to increase palliative care clinical trial expertise. The palliative care services within the VCCC alliance presented substantial trial development opportunities with large number of patients and established relationships, but few trial-active centers. Objectives: To establish a multi-site "Building Capability in Palliative Care Clinical Trials" program as a service development, and to assess the strategies, activities, and the outcomes resulting from this program. Methods: A series of strategies and activities were developed linked to the key program objectives of increasing the number of clinical sites and skilled clinicians conducting clinical trials, increasing the number of trials available and patients participating, broadening research opportunities in palliative care, and establishing the program sustainability. Results: In the two years of implementation, the program resulted in the establishment and conduct of several Phase 4 postmarketing pharmacovigilance studies, nine Phase 2 and 3 trials across five palliative care services, and a Phase 1 clinical trial. During the program, 150 patients were recruited to clinical trials, and 258 prospective pharmacovigilance monitoring cases were recorded. Five investigator-initiated trials were developed by clinical trial fellows and achieved competitive (n = 3) or commercial (n = 2) funding. Clinicians reported that undertaking clinical trials had increased attention to the evidence base of care provision, and increased service research activity more broadly. Long-term sustainability remains a challenge, particularly in the context of the COVID-19 pandemic. Conclusions: Clinical trials in palliative care services are feasible, acceptable, and result in increased attention to the evidence base of care. The strategies detailing the framework, activities, and outcomes have been collated to facilitate implementation of clinical trials in other sites and with other trial-naive disciplinary groups.

Objective The Victorian Voluntary Assisted Dying Act 2017 (the Act) exposed a spectrum of opinions regarding euthanasia and physician-assisted suicide amongst Victorian palliative care physicians leading to sometimes acrimonious debate. The profession was unable to articulate a unified role in respect of VAD. Method A collaboration between psychiatry and palliative care led to a series of group discussions in order to prepare for the Act and to re-establish professional cohesion. Results Although the meetings revealed a plurality of views regarding VAD amongst palliative care physicians, the majority were firmly against the Act. Early meetings revealed strong feelings of shock and an inability to proceed. Previous debates resurfaced between those in support and those not in support of VAD. Over time, there was increased acceptance of the need to adapt to the presence of the Act in order to limit its impact on the robust relationship with the patient central to the practice of palliative care. Conclusions The implementation of VAD legislation requires an active process to address the challenges it represents for palliative care physicians. Collaborative facilitated meetings can help re-establish group cohesion through affirming the core principles of palliative care which remain independent of VAD

IntroductionAdequately addressing the needs of patients at the end of life and their relatives is pivotal in preventing unnecessary suffering and optimising their quality of life. The purpose of the iLIVE study is to contribute to high-quality personalised care at the end of life in different countries and cultures, by investigating the experiences, concerns, preferences and use of care of terminally ill patients and their families.Methods and analysisThe iLIVE study is an international cohort study in which patients with an estimated life expectancy of 6 months or less are followed up until they die. In total, 2200 patients will be included in 11 countries, that is, 200 per country. In addition, one relative per patient is invited to participate. All participants will be asked to fill in a questionnaire, at baseline and after 4 weeks. If a patient dies within 6 months of follow-up, the relative will be asked to fill in a post-bereavement questionnaire. Healthcare use in the last week of life will be evaluated as well; healthcare staff who attended the patient will be asked to fill in a brief questionnaire to evaluate the care that was provided. Qualitative interviews will be conducted with patients, relatives and healthcare professionals in all countries to gain more in-depth insights.Ethics and disseminationThe cohort study has been approved by ethics committees and the institutional review boards (IRBs) of participating institutes in all countries. Results will be disseminated through the project website, publications in scientific journals and at conferences. Within the project, there will be a working group focusing on enhancing the engagement of the community at large with the reality of death and dying.Trial registration numberNCT04271085.

In November 2017, the Victorian Voluntary Assisted Dying (VAD) Act was passed enabling people with a progressive terminal illness to end their life voluntarily. Heated debate abounded including, to some extent within palliative care, which was also challenged with developing processes around the legislation enactment. Objective In response, the lead author convened a series of meetings of palliative care physicians: 1. To share ideas about preparations being undertaken within services; and 2. To re-establish professional cohesion following the divide that the legislation had presented. Design Setting/Participants: A series of three closed meetings were held between the legislation passage and its implementation, with all Victorian palliative care physicians invited to attend. Meetings were facilitated by an experienced psychiatrist from outside the field. Results These meetings proved very valuable as physicians collectively sought to define and respond to challenges, simultaneously reflecting on the personal and professional implications for individuals and the field. Key areas raised including gauging institutional 'readiness' for the legislation through staff surveys; the educational role of palliative care staff of the legislation implications; communication skills training; the role (if any) of palliative care in the processes of VAD; and the perceptions of palliative care itself in health services and the community. It was during the processes of discussing challenges and sharing solutions that the attendees appeared to re-affirm their professional interconnections. A description of the key elements of these discussions may be useful to others who may yet face similar circumstances with the introduction of VAD legislation. This article is protected by copyright. All rights reserved.

To explore the views of Australian emergency department (ED) clinicians about their skills, role and expertise in caring for people with advanced cancer.A cross-sectional electronic survey of doctors and nurses working in Australian EDs was undertaken. Comparisons were made by demographics and whether respondents had received palliative care education.The sample comprised 444 doctors (response rate 13.5%), the majority Fellows (emergency medicine specialists) of the Australasian College for Emergency Medicine, and 237 nurses, from all states, territories and regions (metropolitan and regional). A minority (n=123, 20.6%) felt that the ED was not an appropriate place for patients with advanced cancer to present for acute care, while almost two-thirds (n=397, 64.8%) found caring for such patients rewarding, particularly nurses and those who had received palliative care education; very few (n=40, 6.5%) reported feeling uncomfortable talking to the families of dying patients. A minority (n=129, 21.0%) felt that it was not appropriate for junior medical staff to assess these patients, nurses much more than doctors (42.9% vs 8.5%, p0.001). Over half (n=338, 55.1%) felt sufficiently skilled in managing pain for people with advanced cancer, with Fellows, more experienced doctors, and those who had received palliative care education more likely to feel skilled.ED clinicians in Australia, particularly those who have received palliative care education, feel comfortable and adequately skilled in managing people with advanced cancer presenting to EDs, and most find it rewarding. The importance of palliative care education to emergency clinicians' training should be recognised.

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

This study aims to investigate the number, modality and indication for imaging studies performed on acute hospital inpatients in the 24 h prior to death. Data were obtained from retrospective analysis of deceased patients from a university affiliated tertiary hospital over a 2-year period and it was found that around one in five inpatients received medical imaging in the last 24 h of their life (364 of 1855, 19.6%).

Background:Despite being a common event in the course of an advanced cancer illness, there is little understanding of patients’ perceptions of hospital Emergency Department presentations.Aim:To explore the experiences and perceptions of Emergency Departments held by patients with advanced cancer and their informal caregivers.Design:Cross-sectional study involving semi-structured interviews with advanced cancer patients and their informal caregivers. Qualitative data analysis was underpinned by a phenomenological approach utilising a data-driven inductive thematic frame.Setting/participants:In total, 19 patients with advanced cancer who presented to Emergency Departments in the previous 6 months and 10 informal caregivers from an Australian public hospital and community palliative care service were interviewed.Results:Patients reported that Emergency Department presentations were largely prompted by worsening symptoms or were a means to expedite hospital admission, with many instructed to attend by their health care provider. The experience in the Emergency Department was described as a time of anxiety and uncertainty with concerns over communication, the general environment and delays in the symptom management highlighted. Long waits were common. Despite this, patients described relief at receiving care. While the Emergency Department was viewed as a safety net for the health system, many believed advanced cancer patients should have alternative options.Conclusion:Relatively simple changes of regular communication updates and early symptom relief would improve patient experience of Emergency Department care. However, since an Emergency Department presentation is frequently serving as a default to access medical care, a significant re-orientation of the health care system is required to meet patient needs.

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

Objective: It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions. Methods: This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semi-structured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care. Results: Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education. Conclusion: The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.

Background Patients with cancer are presenting to emergency departments (ED) for end-of-life care with increasing frequency. Little is known about this experience for patients and ED clinicians in Australia. Aims To assess the barriers and enablers regarding end-of-life care for cancer patients as perceived by Australian ED clinicians. Methods There were 4501 Australian ED clinicians invited through their professional colleges to complete an online survey, using multiple-choice and free-text responses. Results A total of 681 ED clinicians responded, most (84.2%) felt comfortable providing care to the dying and found it to be rewarding (70.9%). Although 83.8% found caring for the dying a reasonable demand on their role as clinician, 83.8% also agreed that the ED is not the right place to die. Respondents demonstrated a wide range of views regarding caring for this patient group in ED through free-text responses. In addition, 64.5% reported that futile treatment is frequently provided in the ED; the main reasons reported were that limitations of care were not clearly documented, or discussed with the patient or their family. Almost all (94.6%) agreed that advance care plans assist in caring for dying patients in the ED. Conclusions Our findings provide important new insights into a growing area of care for ED. Barriers and enablers to optimal care of the dying patient in ED were identified, and especially the reported high occurrence of futile care, likely a result of these barriers, is detrimental to both optimal patient care and allocation of valuable healthcare resources.

Over the course of their illness, a person with cancer is likely to see a number of different healthcare professionals, including those in the emergency department (ED). There is limited research examining the interaction and communication between the involved healthcare professionals when such a patient presents to the ED. This study aimed to explore the views and experiences of interdisciplinary interactions of healthcare professionals caring for patients with advanced cancer who present to the ED. Focus groups and semistructured interviews were conducted with clinical staff working in ED, oncology and community and hospital-based palliative care services. Interviews and focus groups were recorded and transcribed verbatim. Thematic analysis was undertaken by three researchers independently. These themes were then discussed by the wider team and consensus reached on themes and subthemes. Eighty-three healthcare professionals participated in focus groups, and 11 were interviewed. The over-arching theme to emerge was one of a conflict between ideal care and the realities of practice, particularly arising where clinicians from different services were required to work together to provide care. This idea was further understood through a series of subthemes including communication, decision-making and understanding of other services. Participants articulated agreed upon ideals of optimal care for advanced cancer patients across all three services, however there was frequently discord between these ideals and the actual care provided. Service demands and the day-to-day stressors of practice appeared to influence people’s actions and engender conflict

Background: People with advanced cancer frequently present to hospital EDs. International studies report conflicting attitudes towards providing such care and difficulties with communication. The experience of Australian clinicians, however, is not described. Objective: The present study aims to identify issues important to emergency, palliative care (PC) and oncology clinical staff in managing people with advanced cancer presenting to EDs. Methods: We qualitatively explored views of Australian clinicians working in emergency medicine, PC and oncology, via focus groups at two major hospitals and two community PC services in Melbourne, Victoria, and emergency clinicians from all other Australian states and territories via semi-structured telephone interviews. Purposive sampling for both groups ensured representation of experience, discipline and region of work. The focus groups and interviews were audio-recorded, transcribed and a thematic analysis identified issues important to participants. Results: The overarching theme was EDs being ‘caught in the middle’ when providing care to patients with advanced cancer in the physical environment (privacy, noise, lack of information and delay and lack of defined pathways), the available resources (access block and overcrowding, time pressures, competition with other emergencies, lack of alternatives) and the roles and expectations of the staff providing care (seniority and comfort with dying, views of dying in the ED, expertise and comfort in caring for those with advanced illness). Conclusion: Despite limitations in the ED environment and resources, clinicians in oncology, PC and emergency medicine support the important role the ED plays in providing the necessary access and expertise for people with advanced cancer.

Background Delivery of care to people with advanced cancer in the emergency department (ED) is complicated by competing service demands, workloads and physical design constraints. We explored emergency clinicians’ attitudes to the ED environment when caring for patients who present with advanced cancer, and how these attitudes are affected by access to palliative care services, palliative care education, staff type, ED experience and patient demographic, hospital type and region. Methods We electronically surveyed clinicians from the College of Emergency Nursing Australasia, Australian College of Emergency Nursing and Australasian College for Emergency Medicine working in an Australian ED. Results Respondents were 444 doctors and 237 nurses. They reported overcrowding, noise, lack of time and privacy as barriers to care. Most (93.3%) agreed/strongly agreed that the dying patient should be allocated private space in ED. 73.6% (451) felt unable to provide a desired level of care to advanced cancer patients in ED. Clinician attitudes were affected by staff type, experience, ED demographic and hospital type, but not education in palliative care. Conclusions ED environments place pressure on clinicians delivering care to people with advanced cancer. Integrating palliative care services in ED and redesigning EDs to better match its multifaceted functions should be considered.

People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer. This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients. ED (529,377) presentations occurred over the 36 months, of which 2.4 % (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33 %, p

Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated-particularly around ethical and legal issues--and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community.We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized.We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered.Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.

Background: The understanding of what palliative care is, and which patients may benefit from palliative care, has important implications for optimal patient care in all areas of health provision. Aim: To explore the understanding of palliative care by healthcare professionals caring for patients with advanced cancer attending emergency departments. Design: Qualitative study, with two phases: the first, a series of focus groups with healthcare professionals from various disciplines and settings caring for patients with advanced cancer presenting to emergency departments; the second, semi-structured telephone interviews with emergency healthcare professionals across Australian States and Territories, including outside metropolitan centers. The data were audio-recorded and transcribed, with analysis undertaken using a qualitative thematic analysis. Setting/participants: Saturation of themes was reached after 8 focus groups (22 emergency nurses, 21 emergency physicians, 6 oncologists, 6 hospital palliative care clinicians, and 28 community palliative care clinicians) and 11 telephone interviews (8 emergency physicians and 3 emergency nurses), a total of 94 participants. Results: The overarching theme was that healthcare professionals held contradictory understandings of palliative care and its application in the emergency department; subthemes highlighted these inconsistencies when the term “palliative” is used, in understandings of and engagement with palliative care services and in perceptions about the practical utility of palliative care. Conclusion: There are entrenched contradictions and tensions surrounding the term “palliative care”; confronting these is likely to require more than re-branding, and will promote better care for this vulnerable patient group in the emergency department.

Objective:Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated—particularly around ethical and legal issues—and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community.Method:We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized.Results:We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered.Significance of Results:Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.

Objectives Patients who articulate their psychological distress primarily through physical symptoms (referred to as medically unexplained symptoms (MUS)) pose a challenge to the skills of most clinicians, including palliative care physicians. The philosophical underpinnings of palliative care with a stated focus on symptom management and care of the person in their psychosociospiritual context lend itself to the care of these patients. The aim of this study was to investigate the characteristics to improve identification of this patient group within palliative care. Methods Here, we report a case series of 6 patients with severe MUS who were referred to palliative care. We use illustrative case vignettes, examine clinical and demographic characteristics and review the perspectives of the multidisciplinary team to identify the common threads. Results This case series highlights the complexities and challenges that are inherent in providing assessment and care for patients with MUS that present to palliative care. Characteristics that were identified included the clustering of ‘trigger’ symptoms, backgrounds of multiple chronic illnesses and relationship dysfunction. Patient outcomes in this group were universally poor, including the death of 2 patients. Conclusions Knowledge of this patient group is vital given the likely increase in prevalence of MUS as palliative care broadens its focus earlier in the trajectory of illness. The strengths of palliative care, including psychosociospiritual assessment, multidisciplinary input and communication skills holds the potential to accurately identify patients with MUS and allow the opportunity for specialist psychiatric input with the hope of improving outcomes for patients and their families.

It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions.This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semistructured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care.Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education.The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.

Australia’s population is aging and increasing. The palliative care needs of the population are also increasing in parallel, with more patients being referred to services for a broad range of reasons including symptom management, psychosocial support, and end-of-life care. Our study looks at how this manifests at on inpatient hospice in Melbourne, Australia, in terms of discharge destinations and allied health service utilization. We noted a trend in more discharges to residential care facilities, which appeared more likely for those patients who were admitted for assessment or had longer length of stay. Patients who were admitted for assessment also appeared in overall to utilize allied health services more than those admitted for end-of-life care. This information will help tailor resource allocation according to the current trends.

People with advanced cancer frequently present to hospital EDs. International studies report conflicting attitudes towards providing such care and difficulties with communication. The experience of Australian clinicians, however, is not described.The present study aims to identify issues important to emergency, palliative care (PC) and oncology clinical staff in managing people with advanced cancer presenting to EDs.We qualitatively explored views of Australian clinicians working in emergency medicine, PC and oncology, via focus groups at two major hospitals and two community PC services in Melbourne, Victoria, and emergency clinicians from all other Australian states and territories via semi-structured telephone interviews. Purposive sampling for both groups ensured representation of experience, discipline and region of work. The focus groups and interviews were audio-recorded, transcribed and a thematic analysis identified issues important to participants.The overarching theme was EDs being 'caught in the middle' when providing care to patients with advanced cancer in the physical environment (privacy, noise, lack of information and delay and lack of defined pathways), the available resources (access block and overcrowding, time pressures, competition with other emergencies, lack of alternatives) and the roles and expectations of the staff providing care (seniority and comfort with dying, views of dying in the ED, expertise and comfort in caring for those with advanced illness).Despite limitations in the ED environment and resources, clinicians in oncology, PC and emergency medicine support the important role the ED plays in providing the necessary access and expertise for people with advanced cancer.

Background Through the need to develop an acceptable organisational and community policy in alignment with the health service’s Mission, a strategic decision to imbed advance care planning policies into practice as a whole of health service, unit based clinical program has presented many challenges for a “greenfield” 880 bed Catholic faith based health service. For St Vincent’s Hospital Melbourne, this foundational approach, considered different to approaches adopted in many other institutions is likely to be more successful and sustainable within the organisation and in its long term implementation into clinical practice. Aim To present a narrative of the factors, 2 years into implementation, that have had to be considered and systematically worked through, to optimise and build capacity to embed its best CARE Advance Care Planning (ACP) policy as a programme. Methods Review of the best CARE ACP project officer’s workplan development and the progress of actions detailed within the plan and minutes of the organisational ACP steering group taken from November 1, 2013 to June 31, 2015. Results The process demonstrates a significant number of governance, model/framework conceptualisation, communication processes, information technology developments and point-of-care documentation processes needed to be completed as key steps in the 18 month timeline to create a workable and viable clinical program fit for purpose and piloting. Discussion/conclusion It can be possible to develop a whole of health service, foundational ACP system and implementation program. Sharing the learning’s and understandings from our processes, should be helpful for others organisations developing similar approaches.

Background The determination of a preferred course of care presents patients with chronic disease, their carers and clinicians with difficult choices. Advance Care Plans (ACP) document patients wishes and goals of care so these are respected even when capacity is diminished. The best CARE ACP pilot will initiate planning and provide compassionate support during the process in alignment with the Mission of St Vincent’s Melbourne (SVHM). Aim To evaluate the use of ACPs and staff and patient understanding and attitudes to them in the SVHM dialysis unit prior to the implementation of the best CARE ACP pilot program. Methods An audit of ACP documents at SVHM was undertaken and dialysis staff and patient understanding and attitudes to ACPs were surveyed. Results 43 patients had an ACP in the patient records for the period 2012–2014. Mean patient age was 70 and 28 (65%) were female. 28 (65%) of the plans were made by Jehovah’s Witnesses. No dialysis patients had an ACP. 31 staff and 20 patients were surveyed. Dialysis staff thought that ACPs were important and felt that lack of patient knowledge was a major problem. 70% of patients had no or little knowledge of ACPs but 80% thought they were important for care. Perceived benefits included ability to express wishes (84%) and reducing the burden for family (68%). 58% thought they should have an ACP. Discussion/conclusion Evaluation of Advance Care Plans pre implementation of the organisational ACP program demonstrated that plans were infrequently utilised and the majority relate to a specific patient group. Attitudes amongst staff and patients were largely positive but patient knowledge was poor.

Background The development of a systematised advanced care planning process in Catholic faith based institutions has presented challenges that have seen unsustainable unsupported programme. Increasing clinician need, a changing understanding of the role of advanced care planning in routine health care, changing community expectations of the use of advanced care plans and reform in health care quality standards have necessitated a recommitment to develop a sustainable, workable process. Aim To present a narrative of the factors, internal and external to the hospital, that have had to be considered and worked through, to develop a programme in care planning for advanced care at St. Vincent9s Hospital Melbourne that has gained acceptance and led to implementation to be embarked upon. Methods Review of the Advanced care planning working group9s meeting minutes actions and document developments taken over 8 month period June 1 to December 2. Results The process demonstrates the key steps in the 18 month timeline that has brought significant points of development to create a workable and viable policy and guidelines, acceptable within a Catholic hospital9s ethical and clinical framework Discussion Sharing the learning9s will be helpful for others developing programmes in comparable institutions to see how important the linking together of key people and committees in an organisation is to develop the acceptable shared understanding and language within the institutions ethical and clinical framework. Conclusion Setting aside historical challenges, it has been possible to develop a system of advanced care planning processes within a Catholic, faith base, tertiary hospital.

Background The Victorian End-of-Life Care Pathways Coordinating Program was established in response to the recommendations of the Department of Health funded project End of Life Care Pathways in Victoria: Report and Recommendations (2011). Aims ▸ To provide a centralised and coordinated approach to end-of-life care pathway activity in Victoria, focusing on the gold standard Liverpool Care Pathway (LCP). ▸ To support services in planning, implementing and evaluating all end-of-life care pathways (EoLCPs). Methods We investigated end-of-life care (EoLC) activity across Victoria and ways in which emerging activity could be encouraged, supported and sustained. Results EoLC activity varies considerably across services and regions, ranging from preliminary exploration to pathways that are firmly embedded in organisational policy, culture and practice. Many of the pathways are registered LCPs or adaptations of the LCP. Others include the Residential Aged Care End of Life Care Pathway. Resources (current and in development) include: Victorian LCP and Victorian Model Pathway (endorsement from Marie Curie Palliative Care Institute Liverpool is in progress) Suites of generic materials applicable to all EoLCPs National benchmarking through the National Palliative Care Reference Group Opportunities for clinicians implementing EoLCPs to share experiences, including: –Databank of EoL activity in Victoria (publically available) –E-News –Workshops. Discussion End-of-life care is core business and an integral part of accreditation in most health settings. Conclusion This programme supports Victorian health services to develop expertise, confidence and consistency in caring for patients and families in the last hours and days of life.