Sharing Care

Key points

  • Many patients with advanced life-limiting illnesses have complex care arrangements involving multiple providers. There are associated risks to the patient:
    • Fragmentation of decision making, which may not be informed by a holistic assessment
    • Miscommunication or delayed communication between clinicians
    • Patient burden and cost associated with multiple appointments and settings of care
    • Confusion for patients and their caregivers, particularly about who to contact in an emergency, which can lead to inappropriate and unwanted treatment.
  • The GP has an essential role in relation to specialist palliative care services. However their contribution may be limited by being part-time, or by other practice-related factors. Clarification of the care processes for each patient is therefore critical, including who has responsibility for:
    • Maintaining prescriptions for palliative medications
    • Regularly reviewing patients’ symptoms, and assessing their care arrangements
    • Either being available or ensuring availability of home visiting for patients who are no longer able to attend a GP clinic
    • Being available to write a death certificate for patients who wish to die at home.
  • For palliative care patients, there are some situations involving handovers of care where they may be at particular risk of receiving inappropriate treatment, and planning ahead for these is good practice:
    • If requiring transfer by ambulance, or if triple zero is called in a crisis
    • At presentation to an emergency department
    • When travelling away from their local area
    • If transferred from residential aged care facility to hospital
    • If reviewed in a crisis by a medical practitioner who is not familiar with the patient.
    • Provide a Letter on resuscitation and treatment preferences 
  • Strategies to share documentation can improve the quality and safety of care, and reduce unwanted and unnecessary interventions which may result from poor communication:  
    • My Health Record have particular value for patients who are being treated in multiple care settings, or whose clinical situation is complex or is changing
    • Patient-held paper records eg, health summaries, symptom diaries, and medication lists. Health summaries that include contact information for treating clinicians can be important for patients who are travelling
    • Written advance care plans, which describe: who to contact in an emergency, who is the person’s substitute decision maker, and what the patient’s wishes are for treatment in different situations. Once completed, this document should be shared with all treating clinicians and also carried by the patient
    • Case conferencing, which can include GPs either face to face or via teleconference, to plan and document shared care, and negotiate care arrangements
    • Palliative care protocols exist in the ambulance services of several states (SA, NSW) to allow paramedics to respond in a crisis without being required to transport a patient to hospital. Where such arrangements do not exist, consider providing a written plan of care for the ambulance, to relieve paramedics of the obligation to perform CPR on a palliative care patient who is actively dying, or to transport them to an emergency department.

Case conference resource guide

This resource guide was developed to assist general practitioners who wish to organise or participate in case conferences for patients with complex needs.

Further information: Shelby-James TM, Butow P, Davison G, Currow DC. Case conferences in palliative care - a substudy of a cluster randomised controlled trial. Aust Fam Physician. 2012 Aug;41(8):608-12.

Ref: Albury Wodonga Regional GP Network. Case conferencing resource guide. Wodonga (VIC); Albury Wodonga Regional GP Network. (197kb pdf) 

Ambulance protocol for palliative care NSW – Authorised Adult Palliative Care Plan

The Authorised Adult Palliative Care Plan was designed in NSW, but similar information would be helpful for ambulance transfers in any state. It defines care choices for a patient in the event of an ambulance call-out, and allows emergency care to be provided by paramedics in the home where appropriate. It can prevent initiation of inapproprate or unwanted resuscitation efforts, and provide contact information for paramedics to request guidance.

Further information: Ambulance Authorised Adult Care Plans

Ref: Ambulance Service of New South Wales. Authorised Adult Palliative Care Plan: Respecting patient wishes. Rozelle (NSW); Ambulance Service of New South Wales. 

Model letter - For communicating a patient’s resuscitation status and treatment preferences

(Date) __________
To whom it may concern (for example emergency staff and ambulance officers) ______________
Re:  (Name of patient, address, date of birth) ________________________
(Name of patient) _____________has (type of life limiting condition) ____________. In view of (name of patient)’s overall prognosis, CPR/Intubation/intensive care should not be attempted if his/her condition deteriorated, as this would be highly unlikely to be successful and would be inappropriately burdensome. This has been discussed with (name of patient)___________, and his/her (spouse/other caregiver etc)___________ and 'person responsible' (name of person(s))___________, and they agree that CPR/intubation/intensive care should not be attempted. If (name of patient)________________ were to become critically unwell, s/he would wish to be allowed to die naturally and to have full comfort care. (Name of patient)_____________ has requested that I write this letter to document his/her wishes.

(Name of patient)______________ is receiving palliative chemotherapy, so transfer to an acute care facility may still be appropriate at this stage, for example to administer intravenous antibiotics and fluids, if indicated.


(Name of patient)____________ would prefer to remain at home as long as possible and if feasible to die at home.


(Name of patient)_____________ would prefer to avoid readmission to the acute hospital. If s/he develops symptoms that are not able to be managed at home then s/he could be (re)admitted to (name of palliative care unit or alternative place of care)_________________.

(Name of patient)__________________ and/or their family have discussed these issues with (name of clinician)_____________.

For any further information about this patient please contact (GP and/or palliative care service contact information)_______________________

Yours sincerely

(Signature here)_____________________

(Name and designation)___________________
Copies to:              
Community Palliative Care Team
Other specialists involved in the patients care
Home Nurses if applicable

From: HammondCare Palliative Care Service, North Sydney

My Health Record

My Health Record
My Health Record contains a health summary including a medication list and an event summary (for documentating any significant health event - for instance after hours contacts, or contacts with a non-usual GP, and so on). It also allows patients to document their own personal health notes, and their emergency contacts, and it can be accessed by all treating clinicians.

Ref: Department of Health. What is in My Health Record [Internet]. 2018 [cited 2018 Apr 26].

Last updated 13 August 2018