End of Life/Advance Care Planning Module

The following is the Table of Contents of an educational module designed to help teams integrate Interprofessional Practice Protocols.

PDFs are available for a selection of materials included within this module. In some cases, links to an external website hosting the document or other resource are provided.

Contact us if you and your team are interested in receiving the protocol (binder format, available for a fee) or the educational session (in-service, tailored to your needs).

1 Introduction/Project Overview


2 Evidence
       a. GAC Evidence Summary
Improving Care Planning
Recognizing Eligible Patients
b. Endorsed GAC Guideline
• Institute for Clinical Systems Improvement. Palliative Care (Guideline).  2008. Online
c. Additional Guidelines and Literature
• The Gold Standards Framework National Central Team. Full Guidance on Using QOF to Improve Palliative/End of Life Care in Primary Care v25. 2006.
• Munday D, Mahmood K, Dale J, King N. Facilitating good process in primary palliative care: does the Gold Standards Framework enable quality performance? Family Practice 2007; 24: 486–494. Online


3 Strategy & Goals
a. Common Understanding and Vision
Vision Exercise
Physician Needs Assessment
b. Defining Practice Assumptions
c. Reflections and Strategies


4 Implementation
a. Developing the Care Pathway/Action Plan
b. Identifying Roles and Accountabilities
Team Questions
Identifying Roles and Accountabilities
Health Professional Competencies
c. Measuring Outcomes
d. Resources & Community Partners
Identifying Community Partners
Community Resource Worksheet


5 Advance Care Planning Course/Training
• PowerPoint Presentation
• Advance Care Planning Session II Handout
• MJA guideline
Clayton JM et al. Clinical practice guidelines for communicating prognosis and end-of-life issues with adults in the advanced stages of a life-limiting illness, and their caregivers. Medical Journal of Australia 2007;186(12):S77-108. Online
• EPEC ACP Participant's Handbook
The Robert Wood Johnson Foundation. EPEC – Education for Physicians on End of Life Care. Participant’s Handbook, Module 1 - Advance Care Planning. 1999.
• EPEC ACP PowerPoint Presentation
The Robert Wood Johnson Foundation. EPEC – Education for Physicians on End of Life Care. Powerpoint Presentation, Module 1 - Advance Care Planning. 1999.