Table 1 The description of Usual Practice and Intervention

Usual Practice: Community Registered Nurses (RNs) visit patients to provide initial needs assessment, wound care, injections, and other clinical services based on the needs identified. Patients may be given ACP information, but the dissemination is ad hoc, and a prior audit found minimal (0.4%) conduct of ACP and completion of ACDs [in review].

Usual Practice: Existing policy recommends that hospital RNs should introduce ACP to relevant inpatients. In reality, a brochure may be available within the department, but specific introduction of ACP to relevant patients is rarely (1.8%) conducted [in review].

Intervention: Two community ACP Registered Nurses (ACP RNs) were allocated, one per LHD catchment area. Each ACP RN was trained specifically in delivering of NACP service and documentation/completion of ACDs.

• Step 1: Usual community RNs visited patients at their home for usual care. Community RNs applied inclusion/exclusion criteria for all new admissions. For eligible patients, the community RN introduced the one-page double-sided ACP brochure and asked if patients would like to use the free ACP service. If patients accept, the community RN gains formal consent and refers the patients to the community ACP RN.

• Step 2: Community ACP RN contacted patients to arrange visits. Community ACP RNs visited patients (and potentially their carers) at home. On average one to three visits were conducted until an ACD was either declined or completed.

Intervention: Two ACP RNs were allocated to cover two wards in two public hospitals, one per LHD. Each ACP RN was trained specifically in delivering of NACP service and documentation/completion of ACDs.

• Step 1: One-page double-sided ACP brochures were included in hospital admission documentation/information packs and were provided to all new admissions.

• Step 2: ACP RNs reviewed patient journey boards each day on the wards and used inclusion/exclusion criteria to identify eligible patients from all new admissions. ACP RNs visited eligible inpatients and asked if patients would like to use the free ACP service.