Authors: (including presenting author): :
Mak MP(1), Tse LKD (1), Lam N (1)
Affiliation: :
(1) Community Geriatric Assessment Team, Caritas Medical Centre
Keyword 1: :
Community Geriatric Assessment Teams
Keyword 2: :
End-of-Life care
Keyword 3: :
Advance Care Planning
Introduction: :
End-of-Life (EOL) care in residential care homes for the elderly (RCHEs) in Caritas Medical Centre (CMC) was rolled out since Oct 2016 and over thousands of residents were recruited to the program. At the beginning, 3 designated Community Geriatric Assessment Team (CGAT) nurses responsible for the EOL-program e.g. identify eligible patients, initiating Advance Care Planning (ACP) conversation and signing the document etc. At 2016, only 3 CGAT nurses carried out the entire burden of ACP for the district’s EOL population leading to bottlenecks. Since 2023, all CGAT nurses (~16 registered nurses) were required to participate in EOL care gradually and try to eliminate this bottleneck. However, some of them found it difficult to initiate the ACP conversation and subsequent EOL care. They played a passive role in ACP conversation. Training is required to support CGAT nurses to provide standard EOL care. Considered that the Advance Decision on Life-sustaining Treatment Ordinance was passed on 20 Nov 2024 and it would be effective on 29 May 2026. With increased awareness and acceptance of EOL care, it was expected the signing of DNACPR and ACP in RCHEs would be increased. Recorded on 30 Nov 2025, 64 RCHEs with 4428 residents were covered by CMC CGAT. There were 300 active cases under the program, meanwhile 200 lived residents / relatives declined to join the program after the discussion. The reasons for decline include refusals by patient/relative (46%), improved conditions (25%), pending relative reply (14%) etc. With the increasing demand for EOL care in RCHEs, CGAT nurses should be equipped with adequate EOL knowledge and skills. Therefore, an ACP workshop was held on 15 Aug 2025, a pre- and post-workshop questionnaires were administered, In order to: (1) measure change in knowledge, attitude and self-efficacy regarding ACP before and after the training, (2) identify areas for additional coaching or mentorship.
Objectives: :
1) Role Transformation Transform the CGAT nurse role from focused on assessment and basic nursing care to comprehensive primary nurse capable of EOL care and ACP facilitation, with 90% of CGAT nurses demonstrating competency in EOL care principles through clinical evaluation within 6 months 2) System integration CGAT nurse as a case manager and the primary point of contact for ACP and EOL care for elderly residents in RCHEs
Methodology: :
This study targeted all CGAT Registered Nurses. The intervention comprised four components: First, a structured training workshop lasting two hours covered education and clinical communication regarding ACP, legal/ethical considerations, and essential nursing skills in subcutaneous infusion and EOL care. Secondly, all CGAT nurses were required to complete the e-Learning module 1-12 on Hospital Palliative Care Nursing at the end of Dec 2025. Thirdly, a mentorship and coaching program was established, where palliative care Advanced Practice Nurses and experienced CGAT nurses conducted joint visits and provided support and individual coaching for nurses initiating ACP conversations with patients and relatives. Fourthly, the workflow was redesigned to enable CGAT nurses to systematically identify ACP opportunities during initial resident assessments, initiate ACP independently, and utilize updated documentation templates and referral pathways. Fifthly, bi-weekly case-sharing sessions were held following successful new ACP enrollments to promote experiential learning and normalize the practice. Data collection included both quantitative and qualitative elements.
Result & Outcome: :
1) CGAT nurse competency and confidence Pre and post workshop questionnaire was conducted to evaluate the workshop effectiveness. The key findings are summarized as follows: i. Belief that ACP is an important part of nursing care: The percentage of nurses who agree or strongly agree increased from 54% in pre-test to 77% in post-test with an improvement of 23 percentage points. ii. Comfortably discussing EOL issues with patients: Agreement rose markedly from 38% to 77% (improvement of 39 percentage points). iii. Willingness to conduct ACP with patients or their families: Increased from 46% to 85% agreeing/strongly agreeing (with 39% improvement after workshop). iv. Belief that ACP helps reduce patient and family anxiety: Rose from 62% to 85%. v. Perception of support from seniors/supervisors for conducting ACP: Showed the largest gain in one area from 46% to 92% (improvement of 46 percentage points). vi. Confidence in initiating an ACP conversation: Increased from 61% to 92% that nurses with moderate to very confidence (improvement of 31% points). vii. Confidence in conducting ACP independently within the scope of practice: improved dramatically from 38% to 92% that nurses with moderate to very confidence. 2) All CGAT nurses (100%) had completed the e-Learning modules 1-12 on Hospice Palliative Care Nursing on or before 31 Dec 2025. 3) From Aug 2025 onward, all CGAT nurses started the EOL case screening and assessment with the coaching of PC APN or experienced CGAT nurses. 4) From Aug 2025 to Jan 2026. 15 CGAT nurses out of 16 (93%) had initiated at least one ACP discussion with patients / family members and signed ACP document with the supervision of PC APN or experienced CGAT nurses. 5) In 2025, 12 sessions of case sharing had been conducted by CGAT nurses and PC APN has provided feedback on how to handle the physical and emotional problems of patients and their families regarding EOL. In conclusion, the workshop demonstrated effectiveness in increasing knowledge on EOL care and CGAT nurses’ confidence to initiate ACP independently. With the support from PC APN, increase nurses competence in EOL case screening, start ACP discussion and complete ACP independently.
