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Advanced Care Planning in the Ballina Renal Service

Ballina District Hospital
Project Added:
28 August 2013
Last updated:
10 October 2014

Advanced Care Planning (ACP) in the Ballina Renal Service

Northern NSW Local Health District


The Ballina Haemodialysis Unit is a seven chair satellite facility providing 84 dialysis treatments weekly. The majority of 28 patients are aged 70 years or older with comorbidities including diabetes, cardiac, cardiovascular and haematological conditions.

The aim of the project was to raise the awareness among our patients of Advance Care Directives (ACDs) and to reach a compliance of 80% by Christmas 2010. We have now achieved 84% compliance with the NSW Health ACD Policy. Implementation of the policy required considerable staff up skilling and empowerment. With careful planning, this project has been accepted by the staff and patients alike and is sustainable as part of our core business.

Use of ACDs gives patients a voice in their ongoing medical management and at critical life threatening times when they are unable to advocate for themselves. The patient's right to die and to have a death with dignity is enabled.

Download the Project Report (pdf 67 KB)

Extent of the Problem

According to the NSW Health policy established in 2004, ACDs are to be present in the patient’s medical records for moments when the patient is unable to make decisions for themselves.

In 2009 two incidents occurred whereby staff failed to meet their patients’ needs because of lack of prior knowledge of patient wishes regarding interventions in emergency situations. The patients endured extensive interventions when in fact they each had an ACD in place indicating that they did not want advanced life support interventions.

These incidents highlighted the need for ACDs and appropriate documentation and this led to the development of a project to implement ACDs as a standard component of the model of care for this unit.

Ballina staff were concerned that they had let down their patients. ACDs should be a standard component of patient care, however review of patient records in 2009 within the unit identified that 0% of patients had an ACD on the front of their dialysis patients chart or electronic medical record.

The following barriers were identified through audits, staff and patient feedback and education in-services:

  • Nurses and patients lack of understanding about the process and aims of Advance Care Planning (ACP) and ACD,
  • Nurses identified potential staff, patient and carer barriers to ACP, and
  • Current ACD form was not user-friendly.

There were also the anticipated challenges of the spiritual, cultural and social beliefs of individual patients which were acknowledged and managed with appropriate sensitivity. 20% of the unit's dialysis patients were Aboriginal or Torres Strait Islander (ATSI). Their cultural belief system presented a significant barrier to achieving 100% implementation of ACDs in the unit.

Planning and Implementing Solutions

Having identified and acknowledged staff concerns, the project team developed an education program. Structured in-service sessions were provided utilising the expertise of the renal unit social worker, the palliative care and renal unit clinical nurse specialists (CNSs), and the project coordinator. These sessions included relevant evidence based best practice pre reading, interactive role play, mind and concept mapping and familiarisation with the approved ACD document. Sessions were enhanced through ongoing evaluations and staff feedback. The process was adaptable, flexible and responsive.

Primary Nursing Teams were created and patients were assigned to individual teams. A learning package was given to all team members prior to attending the scheduled in-services. Primary Nurses initiated the discussions with their assigned patients prior to introduction of the ACD package and were available for frank and open discussions concerning ACP. A modified form has been developed as part of our ACD package for staff and patients. This is more user- friendly than the long form in the ACD Policy.

Due to the sensitive nature of ACP and ACD it was important in the initial stages to make sure all nurses were familiar with the appropriate terminology and the medico-legal implications associated with the project. In-service sessions also offered a forum for the expression of individual views and belief and gave participants a chance to understand and respect others belief systems and identify any barriers that may interfere with their ability to participate in the project effectively. It was necessary for staff to have a solid foundation before we could initiate the project so as to appear confident when assisting patients in making life and death choices in their medical care.


Outcomes and Evaluation

The patients' attitudes to the ACD discussions varied. The decision-making process was heavily influenced by the patient's cultural, psychosocial and spiritual needs. Some patients self-initiated discussions but the majority required nursing staff conversation to initiate the ACD end goals. Patients were able to talk to the staff about topics such as death and dying, future goals, and factors influencing their decisions. Patients were empowered to make an informed decision regarding their ACD.

Cultural changes that have taken place revolve around the transparent exchange of views and ideas between nursing staff and nursing staff and the patients. There has been a creation of respectful open communication amongst all participants.

At a time when the average compliance in NSW was between 3-5% within Renal Units, ACDs have been introduced as a standard component of the model of care in the Ballina Renal Unit. We presently have 84% of all our inpatients with ACDs documented both in their medical record and as electronic alert in electronic medical record (eMR). Doctors are aware of patient wishes in a medical emergency.

The project recommendations are that the ACP should be initiated during pre-dialysis consultation workup including the use of "Taking Care of Business: Planning Ahead in Aboriginal and Torres Strait Islander communities" program to meet a target of 100% ACD documentation.

Renal Social workers have commenced initiating ACD, ACP during pre-renal replacement therapy assessment work up. This has had a varied success rate but has decreased the number of patients presenting to the unit without a current ACD.

New ACD forms have been developed with assistance from Palliative Care Unit and 100% of all permanent nursing staff has participated in the in-service programs related to ACD and ACP.

During the past year a number of our patients have withdrawn from active care. ACDs have empowered patient and families, and assist medical management to help the patient die with dignity. This also has the flow on effect of appropriate use of medical resources.

The project has created an additional outcome of respectful open communication amongst all participants.


  • Using Advance Care Directives, NSW Health, 2004.
  • Advance Care Planning, North Coast Area Health Service, NSW Health, December 2008
  • Palliative Care Advance Care Plan, Northern Rivers, General Practice Network, Adapted from a document modified by Warrnambool Palliative Care from Respecting Patients Choices, Austin Health, Victoria ACD, Rev3: 01023020
  • Meehan, K, Advance Directives, The Clinical Nurse Specialist as a Change Agent, clinical Nurse Specialist. 2009;23(5):258-263.
  • Conflict Resolution in End of life Settings, NSW Health, 2010.
  • Up-to-date – Ethical issues in the care of the patient with end-stage renal disease, Tony Dash MD (May 2010)
  • Taking care of Business, Planning ahead in Aboriginal and Torres Strait Islander Communities. NSW Department Ageing, Disability and Homecare. July 2007
  • Advance Care Plan for the Patient with Advance Disease. Northern Rivers General Practise Network


Nurse Unit Manager, Renal Service
Ballina Hospital
Northern NSW Local Health District
Phone: 02 6620 2111

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