Oral Presentation Palliative Care Nurses Australia Conference 2020

I want you to know my wishes (71907)

Davinia Seah 1 , Cindy Grundy 1
  1. Sacred Heart Health Service, Darlinghurst, NSW, Australia


People living in Residential Aged Care facilities (RACFs) are typically frail, have multiple comorbidities and are dependent on carers. Despite this, it is unclear how many residents have their preferences for health care documented or how clearly they are documented. An Advance Care Plan (ACP) is a process which documents a person’s values, preferences and preferred outcomes, providing a guide for future healthcare decision making. However, plans need to be readily accessible and properly completed to be effective.


This ongoing project aims to record and describe the incidence and quality of ACP in all 23 RACF’s serviced by the Sacred Heart Community Palliative Care Team (CPCT).


Resident’s records at two RACF’s were reviewed between June and July 2020. Demographic data, number of comorbidities and identifying residents known to CPCT was recorded. Incidence and details about ACP documentation was also recorded and described.


Of 134 residents in two RACFs, the median age was 90 years and the average number of comorbidities was eight.  71% of residents were capable of limited self-care and 11% were bedbound. Seven residents were known to the CPCT.

Most residents had a formal statement of wishes documented (79%) and a named substitute medical decision maker (80%). Nine of the advance care directives did not have a resident signature and 8% of the ACP did not have a date. 

The documentation regarding instructions related to transfer to hospital and cardiopulmonary resuscitation (CPR) was clear for 45% and 67% respectively. ACPs could be stored in multiple locations. Most ACPs were easily found within 15 minutes.


The project is collecting valuable data and evidence that describes the state of ACP in facilities and may guide future change.


Not all residents in RACFs have an ACP.  Even having an ACP does not guarantee a clear plan. There can be difficulty interpreting resident’s wishes with regards to being transferred to hospital or having CPR, and documentation may not necessarily meet legal requirements. Collaborating with RACFs to improve ACP processes and documentation may be needed to ensure residents receive care that aligns with their wishes.