Advance Care Planning (ACP) is a process of reflection, discussion and communication that enables a person to plan for their future medical treatment and other care, for a time when they are not competent to make, or communicate, decisions for themselves. ACP could significantly improve the quality of care provided to patients with advanced diseases by allowing patients to receive patient centred care and avoid unwanted/inappropriate hospital admissions and treatments.

Project Status

Completed Projects

Chief Investigators

A/Prof Joel Rhee, A/Prof Gideon Caplan, Ms Anne Meller, A/Prof Peter Gonski, A/Prof Vasi Naganathan, Dr John Cullen, Prof Nicholas Zwar, Prof Andrew Hayen, Ms Julie-Ann O’Keefe, A/Prof Ben Harris-Roxas

Other team members

Dr Karolina Krysinska, Ms Kate Marshall, Ms Melissa Cassey (SLHD), Ms Emily Mackinlay (SESLHD), Ms Catherine Molihan (SESLHD)

Project Rationale

Hospital wards are not ideal setting for ACP and there is evidence that ACP decisions made when acutely unwell differ from decisions made when medically stable, so outpatient clinics are a better setting in which to conduct ACP. There is however lack of training and support for staff working in outpatient clinics to firstly identify patients who may benefit from ACP, and secondly to facilitate ACP.

Project Aim/s

This research aims to trial and evaluate on patients attending NSW hospital clinics with advanced illnesses identified as potentially having supportive and palliative care needs, a model of ACP that seeks to: (i) increase the uptake of ACP by patients; and (ii) encourage NSW Health clinical services and GPs and other health professionals providing care for the patients to incorporate ACP into routine care.  

This study seeks to determine if this model of ACP will reduce acute health resources utilisation; improve the quality of care for patients and caregivers / family; and result in improved understanding and uptake of ACP by health professionals.

Project Design and Method

Pragmatic Randomised Controlled Trial


Study protocol paper in preparation


Karolina Krysinska Phone: 02 9385 1506 Email:

Key Partners

South Eastern Sydney Local Health District


NSW Health Translational Research Grant Scheme

Project lead centre
South Eastern Sydney Research Collaboration Hub (SEaRCH)
Project stream
Health System Integration and Primary Health Care Development
Project start date
Project end date