In late 2012, the NSW Minister for Health and Minister for Medical Research, the Honourable Jillian Skinner MP launched the NSW Government plan to increase access to Paliative and End of Life care 2012 – 2016. The Plan calls for new models of care that foster partnerships and establish linkages across services and sectors to develop an integrated network of primary care, specialist palliative care, aged care and community services.


What is the Vision?

The Vision is to ensure that all NSW residents have access to quality care based on assessed need as they approach and reach the end of their life.

With the assistance of funding from the ACI, NNSW Integrated Care has been successful in recruiting Anna Law to the 12 month dual role of Integrated Care – End of Life Project Officer.

Click here to read the Palliative and End of Life Care, A Blueprint for Improvement. A progress report from the ACI Palliative Care Network Executive Committee - September 2014.


What are the Aims Locally?

End of Life Care - Northern NSW Integrated Care Initiaitve

The End of Life Care (EOL) Project aims to improve the care we provide for our community in the Richmond Valley. The project will work in collaboration with acute and primary care services.

This is an important initiative for this area as it will improve the quality of patient/carer end of life experience.

The project will look at 4 main areas:



Digital Communication

To improve the knowledge, awareness and use of Advance Care Directives in the Richmond Valley.

  • 2 pilot groups initially will work to streamline patient/carer/health worker use of Advanced Care Directives.
  • Once the process is working effectively for these two groups we will introduce to a wider group of patients.



Health Care Clinician Education

To provide regular education to primary and acute care providers to optimise end of life care delivered

  • Covering all topics from End of Life planning to Transitioning to End of Life Care and Dying.
  • Suitable for acute and primary health care providers.



Community Engagement

To provide adequate education to key groups in the community.

Work with the community on:

  • What is end of life care planning about?
  • Advanced Care Directives
  • Enduring Guardian and Power of Attorney.



Ambulance and Advance Care Directives

To have a smooth communication flow between Ambulance, Primary and acute health care and patients/carers/family.

  • Develop processes to facilitate transition to End of Life

The Last Days of Life toolkit

EOL Project Officer, Anna Law has hit the ground running, launching the "Last Days of Life Toolkit is a pilot currently being run by the Clinical Excellence Council to improve last days of life care provided within acute facilities.

The Last Days of Life toolkit has been launched in Lismore Base Hospital adult ldol-logowards in late November 2016.

Lismore Base Hospital is piloting 2 forms:

  1. Initiating Last Days of Life Management Plan — Adult
  2. Comfort Observation and Symptom Assessment Chart — Adult.

The toolkit also has the additional Medication Management charts to aid in appropriate medication charting for the dying patient.


End of Life Multidisciplinary Meetings

Anna Law has coordinated regular  meetings scheduled bi-monthly on the 4th Friday, 7am-8am with a light breakfast provided.

Dates for 2017 are:

  • 24th Feb 2017
  • 28th April 2017
  • 23rd June 2017
  • 25th August 2017
  • 27th October 2017.

Each meeting will discuss what really matters in the end. Real cases are presented and discussed with the focus changing each each session – and only decided the month before to keep it relevant. It is open to all Clinicians aiming particularly at new staff.

For more information contact Anna Law on Anna.Law@ncahs.health.nsw.gov.au.


End of Life Newsletter – February 2017
End of Life Newsletter – December 2017
“It’s Now or Never” Meaningful Conversations at End of Life Care End of Life Care Project Officer, Anna Law is running regular workshops entitled – “It’s Now or Never”. The purpose of the Education Day is to provide knowledge and skills for clinicians to enter into end of life conversations with their patients and loved

ACI Guardianship Project

Guardianship project Historically, patients who are waiting for Guardianship matters to be heard by the NSW Civil and Administrative Tribunal (NCAT) experience extended lengths of stay with associated significant costs to the organisation since they must remain in hospital while waiting for the outcome or determination of a guardianship hearing. NCAT Guardianship Division conducts hearings

Guardianship Training Day

Guardianship Training Day On 14 February 2017, Allied Health and Nursing staff from the NNSWLHD recently attended a Guardianship Training day in Ballina hosted by the North Coast Primary Health Network. Key learnings from the day included: A new NSW Health Guideline: – The Guardianship Application (GA) Process for Adult Inpatients of NSW Health Facilities