Mrs Ros Kirk1
1Capital Health Network – ACT PHN, Canberra, Australia
Biography:
Ros is the Palliative Care Planning Manager for Capital Health Network, ACT’s Primary Health Network. She is an RN who has worked in Specialist Palliative Care for over 20 years. Ros is also a trained clinical supervisor and provides clinical supervision to healthcare professionals that care for patients as they approach end of life.
Abstract:
Background:
Chronic illness remains the leading cause of death in Australia, yet patients with these conditions are often underrepresented in Specialist Palliative Care (SPC) referrals. General Practitioners (GPs) play a crucial role in managing patients with end stage chronic illness, often until death. However, lack of formal integration of palliative care within general practice can hinder effective end-of-life (EOL) planning, symptom management and timely SPC referrals.
Aims:
The PCiGP1 Quality Improvement (QI) activity aimed to foster general practice learning and continuous quality improvement in palliative care by reflecting on the last 12 months of life of patients with end-stage chronic disease. By reflecting on how care might have been different if these patients had been identified as ‘palliative’, practices generated ideas for change to improve the recognition and support of patients with end stage chronic illness.
Methods:
GPs reviewed the last year of life patients with end-stage chronic disease that they had managed over the past 2 years. The project used a tailored Capital Health Network (CHN) Retrospective End of Life Reflection (REoLR) audit tool alongside the CHN Plan-Do-Study-Act QuIK Cycle to systematically review cases. REoLR findings were used to generate ideas and practices were supported to implement chosen activities for improvement.
Results:
Increases in:
–Patients identified in last 12 months of life
–Completion and documentation of Advance Care Plans (ACP)
–Patients referred to Home Medicines Review
–End of life (EOL) planning (regular monitoring and timely referral)
–GP knowledge of palliative referral pathways and available clinical support
–GP confidence in the palliative approach to care and symptom management.
Conclusion:
PCiGP1 improved palliative care delivery through structured reflection and continuous QI. Early palliative identification enabled more coordinated, patient-centred care, reinforcing the value of integrating palliative approaches into everyday general practice.