Developing a system of advance care planning across a large metropolitan health service: The Sydney South West My Wishes Program

NSW Health has provided funding to eight Area Health Services (AHS) since mid-2008 to promote a more systematic approach to advance care planning (ACP). While there has been a strong effort to share ideas and resources between the AHSs, there has not been a uniform program or set of resources used across the State.

Sydney South West AHS decided to take a long-term, integrated approach that would be most likely to lead to sustainable changes to practice. The main elements of this approach have been:

 • A comprehensive policy that draws together the various aspects of ACP
 • Clear statements about staff responsibilities regarding ACP
 • Statement of Values and Wishes and Record of ACP Discussions forms that have
   been implemented as part of the AHS medical records system
 • Flagging that a patient has an ACP within the electronic medical records system
 • Comprehensive guidelines for staff in initiating and conducting ACP discussions
 • A range of consistent information sheets for the general public and staff from hospitals,
   residential care, community and general practice settings
 • Training programs for staff from across different care settings
 • Collaboration with local residential aged care facilities and Divisions of General Practice.

The policy, forms and resources have been organised as parts of a unified program called the Sydney South West My Wishes program All information and resources will be located on a website with open access. The program is in the early stage of implementation and will be accompanied by ongoing evaluation.