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Advance care planning in the hospital setting
Dying in acute care
  1. P Saul
  1. NSW Health, NSW, Australia


The demography of dying in Australia, as in other developed countries, has shifted dramatically in a single generation. Cause of death, place of death and mode of dying are all unrecognisable to the generation currently facing death. The fastest growing causes of death in Australia are dementia (now third commonest) and diabetes (sixth), two thirds die in acute care, most from a decision to withhold or withdraw treatment.

Acute care has largely failed to embrace its role as the dominant place of death, and remains committed to a set of defaults that I call the DED (the Do Everything Defaults). Palliative Care has failed, in many cases, to fill the gap.

This paper details a series of projects running in NSW, Australia that attempt to link our advancing knowledge of advance care planning with existing systems of care. Specifically,

  • introducing new admission processes that capture preferences for substitute decision makers

  • using a risk of death tool administered by nurses to trigger a MOLST process

  • modifying the existing deteriorating patient systems (including MET)

  • modifying observation charts for those in the process of dying that parallels existing charts but with altered parameters. These would function as an alternative to existing end of life pathways, which have not been a great success.

The aim is to produce a ‘chain of palliation’ to parallel the dominant ‘chain of survival’.

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