QI in Action: Recognising Dying to Improve End-of-Life Care
We spotlight Clare Warren’s quality improvement project which focuses on improving quality practice of in-home palliative care across the Western Sydney Local Health District.
The Quality Improvement Lead (QIL) Program is a 9-month training course run by the ACHS Improvement Academy, supporting participants in implementing quality improvement projects within their own organisations.
QIL graduate, Clare Warren, Clinical Nurse Consultant Quality, Safety and Risk Officer, Silverchain worked on a project titled, ‘Death Outside the Terminal Phase: Recognising Dying,’ aimed at improving recognition of the terminal phase in palliative care, ensuring that patients and their families receive the appropriate support during this critical stage.
Silverchain provides specialised comprehensive in-home palliative care to over 7,000 people across Australia each year. The organisation has an ongoing partnership with the NSW Government to deliver a community palliative care service to people in the Western Sydney Local Health District (WSLHD).
Project Background
Recognising when a palliative care patient is entering the terminal phase is a crucial aspect of quality end-of-life care. In 2023, data from the Palliative Care Outcomes Collaboration (PCOC) revealed that 36% of patients who had died at home in 2022 had not been formally recognised as being in the terminal phase. This raised concerns that critical conversations around end-of-life care planning may have been missed.
The project aimed to reduce the percentage of deaths occurring outside the recognised terminal phase across the Western Sydney Community Palliative Care Service to 15% by 2025 and to less than 10% by 2026.
Improving Clinical Confidence in End-of-Life Recognition
For individuals who choose to die at home, effective communication and planning are essential. Recognising the terminal phase enables clinicians to have timely discussions with patients and their families about what to expect, address concerns, and ensure a peaceful and well-supported end-of-life experience. Missing this recognition risks inadequate preparation, leading to distress for both the patient and their loved ones.
Understanding the Barriers
A retrospective analysis of clinical notes from a 2022 audit helped identify key barriers to accurate recognition of the terminal phase. Staff surveys highlighted two major challenges:
Knowledge and experience gaps: Some clinicians lacked confidence in assessing when a patient was entering the terminal phase.
Fear of difficult conversations: Many clinicians hesitated to engage in compassionate end-of-life discussions, concerned about emotional reactions or making an incorrect assessment.
Consumer feedback from documented client experiences further reinforced the need for improved communication and recognition processes.
Implementing Change
A series of small-scale improvement were introduced to test and refine strategies for better end-of-life care. The first step focused on training staff in recognising and documenting key palliative care phases, which led to an immediate reduction in deaths occurring outside the terminal phase by 13% in both April and May 2023. Further training was also introduced to help clinicians identify the signs of imminent death and have sensitive, compassionate conversations with families.
However, recognising that education alone is not enough, additional steps were taken to improve processes and support staff. Updates to the electronic clinical record system were made to ensure consistent and accurate documentation. Palliative care assessments were expanded beyond nursing staff to include all clinicians, and these assessments were embedded as a required part of referral documentation. To further support staff, a structured mentoring and buddying program was introduced, helping new team members build confidence in end-of-life care discussions.
Towards Compassionate Care
The project has shown positive changes, with early feedback highlighting improvements in staff confidence and patient care. Next steps include routine audits of terminal phase documentation to monitor progress, sharing insights with the Silverchain Palliative Care Network to inform further improvements, and strengthening coordination between clinicians and families to ensure continuity of care.
Explore projects from QIL Program Graduates
You can read more projects like this in the QIL Projects Summary booklet undertaken by QIL 2021-2023 participants over the course of our 9-month program.
The booklet contains summaries of real work-based improvement projects across various healthcare categories including acute healthcare, community, drug and alcohol services, partnering with consumers and more. Project Summaries booklets are available for viewing here.
