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Decision Assist is promoting best practice outcomes in end of life care

05 May 2015

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Decision Assist is promoting best practice outcomes in end of life care

In Australia, the demographics of death are changing.

Today, most people die an expected death from one or a combination of various chronic progressive conditions. As most deaths are expected, death can be planned for, and required care delivered in a pre-emptive fashion.

As primary health care providers for older Australians, including those in residential aged care facilities, GPs are uniquely placed to guide patients through their end of life care journey.  Although GPs often indicate that they rarely practice palliative care, the changing demographics in Australia mean that GPs are increasingly caring for greater numbers of people with advanced chronic conditions that are likely to lead to death in the near future. For this patient cohort, early identification of needs will help promote the best quality of life. Given this, it may be beneficial for GPs to reconsider how they define and practice palliative care to help their patients, with malignant and non-malignant conditions, achieve optimal outcomes.

To support GPs to deliver palliative care and advance care planning to this patient cohort, the Australian Government has funded Decision Assist. The program provides a range of clinical support and specialised education initiatives for GPs and aged care staff. Many of the GP educational opportunities are accredited with the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM).

The GP palliative care education activities are based on a palliative framework of care. The framework uses three prognostic trajectories, to support GPs to proactively manage their patients’ care as it transitions from curative to palliative and to facilitate a quality end of life according to patient preferences. It is founded on work undertaken in the UK [i] and Australia.[ii]

The framework commences with a trigger question “Would you be surprised if the person died in the next 6 to 12 months?” which is answered by the GP using clinical knowledge, personal knowledge of the patient, clinical intuition and/or by using clinical prognostication tools. This question can be embedded into routine practice in a systematic way, for example at the 75+ health check or during regular visits by this patient cohort. 

If the patient has a prognosis of greater than 6-12 months (first trajectory), the answer to the surprise question is “yes”. The associated key clinical process is advance care planning, an interactive ongoing process of communication between a competent person/substitute decision maker and all carers, focussing on the person’s preferences for future care.

If the patient has a prognosis of less than 6-12 months (second trajectory), the answer to the surprise question is “no”. The associated key clinical process is case conferencing aiming to identify clear goals of care so that all carers are “on the same page”.

In the third trajectory, a diagnosis of dying has been made with a prognosis of usually less than a week. The key clinical process is development of a terminal care management plan to support the person to die at home or in an aged care facility.

The framework promotes proactive management of clinical needs that typically emerge in the last year of life, enabling plans to be developed in accordance with the patient’s personal choices.

GP education

The framework underpins the GP palliative care educational opportunities offered through Decision Assist.  These include a clinical audit for GPs that is offered by the Australian and New Zealand Society of Palliative Medicine (ANZSPM) and offered during the 2014-2016 triennium. The audit has been allocated 40 QI&CPD points with the RACGP (enables GPs to meet their quality improvement activity requirements) and 30 PRPD points with ACRRM. It is an opportunity for GPs to review their approach to managing the care of older Australians with advanced life limiting conditions living in the community.

There is a case-based interactive workshop available, which is conducted at national and state GP conferences and also through organisations that provide education to GPs. The workshop is accredited for 3 QI&CPD points with RACGP and 2 core points with ACRRM.  

An online education module is offered as an alternative to the workshop, which can be accessed via gplearning (RACGP members) or RRMEO (ACRRM) members. This module is accredited for 3 QI&CPD points with RACGP and 2 core points with ACRRM. 

An Active Learning Module (RACGP)/Theory Practice Activity (ACRRM), is also available and is accredited for 40 QI&CPD points with RACGP and 30 PRPD points with ACRRM.  It gives GPs an opportunity to increase their capacity to manage the care of older Australians with advanced progressive life limiting conditions living in the community.

From May 2015, GPs can also participate in an online ‘case of the month’ discussion, which will be moderated by a palliative medicine physician. Cases discussed will be typical of those seen in GP practices - older patients with life limiting conditions, both malignant and non-malignant, for example COPD, heart failure, dementia, frailty syndrome.

And in late 2015, Decision Assist is also planning a series of specialist advance care planning workshops for GPs at locations around the country.

Clinical support

In addition to these educational opportunities, Decision Assist has developed a suite of resources to make it more convenient and timely for GPs to access authoritative information on advance care planning and palliative care. These include a national Phone Advisory Service – 1300 668 908 – which has specialist palliative care staff available 24/7 to provide advice on all palliative care issues ranging from symptom control and medication management, to psychosocial support and bereavement advice.

For GPs seeking assistance with advance care planning, specialist operators are available on 1300 668 908 from 8am until 8pm daily, and can answer inquiries ranging from communications needs, to documentation, ethics and legalities. To ensure GPs are well supported in instituting the palliative approach, Decision Assist is also providing specially tailored education and training opportunities for Practice Nurses and aged care employees in both advance care planning and palliative care.

Get the App

The program is also soon to release a mobile phone app called ‘PalliAGED’, which will deliver an online tool for GPs to access prescribing and management advice as well as tips for identifying older patients who could benefit from a palliative approach to care. Download details are available at

The Decision Assist program has been developed and implemented by a consortium representing leading national medical, aged care and academic institutions, including Austin Health, the University of Queensland, CareSearch, Queensland University of Technology, Leading Age Services Australia (LASA), Aged and Community Services Australia (ACSA) and Palliative Care Australia.

It aims to support the important work already being done by specialist providers in the sector, and prevent unwanted interventions, including hospital admissions, to ultimately assist older Australians access the type of care that best meets their needs and wishes during the final stages of life.

More information

For more information visit

[i] Gold Standards Framework. [cited 1 April 2015]. Available from:

[ii] The Palliative Approach Toolkit - Module 1: Integrating a palliative approach. Brisbane: The University of Queensland; 2012.

Published: 05 May 2015