Sunraysia Community Health Services

“We’re still a bit death-illiterate as a community,” says Melinda (Mel) Livens, Clinical Nurse Consultant at Sunraysia Community Health Services. “We don’t like to talk about dying, but we need to change that.”

In her view, planning for death should be as normal as writing a birth plan: “It doesn’t necessarily mean it’s going to go to plan, but if you don’t have one, you will get a lot of active treatment.”

While some may want every possible intervention, others would rather spend their final days at home, surrounded by loved ones – not in a strange and sterile emergency department.

Yet fewer than 5% of the 1,700 Australians who die in aged care each year have an advanced-care plan. Without one, many die receiving treatment they don’t want and missing out on the coordinated and compassionate care they deserve.

The toolkit 

The Aged Care Royal Commission called for better palliative care across the country, but Ms Livens says raising the rates of advanced-care directives has been “excruciatingly hard”.

Part of the problem is our collective discomfort talking about death.

But it’s also structural; staff turnover in aged care is high, especially in rural Australia, and training around these sensitive conversations can be inconsistent.

That’s why Sunraysia partnered with La Trobe University’s School of Psychology and Public Health to create the Palliative Care Assessment Toolkit (PCAT). It includes a checklist for nurses, best practice guidance on anticipatory medicines, and clear referral pathways that help coordinate care.

And it’s already making a difference. The 2023-24 pilot across five aged care homes in the Mildura region led to a jump in end-of-life care plans from 55% to 88%. Medication availability almost doubled, from 55% to 100%, and residents reported better psychological and spiritual support.

The collaboration with the School of Psychology and Public Health on this project began when Professor Hanan Khalil, Associate Dean of Academic Partnerships, approached them with grant funding to improve palliative care in regional and rural Australia.

Prof Khalil, a registered pharmacist, has extensive experience in palliative care and research designed to improve the quality and performance of health services. The teams had already been working together to assess how anticipatory medicines – such as the pain relief needed to make people’s final days more comfortable – were being used and accessed.

“We looked at the gaps, and we found that we could use our experience to help develop a tool for nurses to use with palliative care residents,” Prof Khalil says.

Sunraysia, the largest community health service in the region, brought real-world insights from the frontline, while the La Trobe researchers ensured the intervention was grounded in high-quality evidence.

“At the end of the day, we’re nurses not academics,” says Ms Livens. “Working in an academic partnership gives the work more weight and clarity. They highlight gaps and help us improve these processes.”

Understanding the problem

Their research revealed both staff and patients didn’t know enough about palliative care. Communication between nursing homes, hospitals and families was inconsistent, and there was no standardised tool to assess palliative needs.

One key intervention was introducing ‘care needs rounds’, which were regular meetings between palliative care nurses and aged care staff to identify residents whose health was deteriorating and to start important conversations earlier.

This structured approach helped staff ask critical questions, such as whether anticipatory medicines were needed, whether the family were aware of the situation, and whether an advanced-care plan was in place.

“The benefit is that people aren’t going to the hospital unnecessarily,” says Ms Livens. “Families are more prepared. It doesn't come as a complete shock. The nursing team and the doctor knows the patient’s wishes.”

This means more people can die with dignity, in a place of their choosing, and with loved ones nearby.

Crucially, La Trobe researchers didn’t deliver the new tool and walk away. They helped provide training and support to embed the tool into routine practice.

“With high staff turnover, you’re constantly educating and re-educating,” says Ms Livens. “If you all have the same tools and speak the same language, you’re on the same page regardless of whether you’re working in the community, hospital or nursing home.”

Prof Khalil says the project’s success means the team is now preparing the toolkit for national rollout. The next step is to digitise the tool and make it freely available to aged care providers across the country.

“If we identify patients early, before deterioration, they will have a better quality of life, and they will end up using healthcare services, like hospital admissions and GP visits, much less,” Prof Khalil says.

The project has strengthened La Trobe’s reputation as a partner of choice for healthcare collaborations. It’s received media coverage and recognition for showing how evidence-based tools can improve outcomes in regional and rural communities.

And the job isn’t done. Improving how Australians die is ongoing work.

“Growth in our area is huge and patient numbers have skyrocketed,” says Ms Livens. “But time is always the barrier.”

Still, she’s optimistic. “It’s exciting work. On average, the state has about 28% of people die at home – but here it’s about 55%. We do amazingly.”