There is agreement that management and staff of RACFs (residential aged care facilities) need to be supported to provide high quality end-of-life care for this growing and vulnerable population including supporting residents to die in their RACF, if that is their preferred wish, and that facilities have adequate resources to enable this to occur. The complex needs of residents and their families have prompted recognition of the importance of using a palliative approach to care in the residential aged care setting. A palliative approach to care includes three clinical processes based on a resident’s prognosis – advance care planning, case conferencing and use of an end-of-life (terminal) care pathway. Advance care planning (ACP) is integral to ensuring that end-of-life care delivered to patients is aligned with their wishes by enabling individuals to state their preferences should they become unable to participate in decision-making.
In 2017 the Improving End-of-Life Care Residential Aged Care Residents Initiative was developed in partnership with the Brisbane South Primary Health Network (BSPHN) and Metro South Palliative Care Service (MSPCS) after a successful pilot project. The aim of the initiative is to support RACFs to embed evidence-based practice in their routine clinical care to support high quality end-of-life care for residents and their families. The recent Productivity Commission Reforms at End-of-Life Care report agrees that end-of-life care should be the RACF’s core business which will require a coordinated approach in supporting the education of aged care nurses, as with upskilling they are well placed to lead and coordinate end-of-life care in RACFs. The initiative aims to provide that coordinated approach to educating the aged care nurses with three projects running simultaneously including the:
- Advance Care Planning project, the aim of this project is to support RACFs to embed an evidence-based ACP program, adapted for individual facilities, in their routine clinical care to support high quality end-of-life care for residents and their families.
- Palliative Approach Link Nurse Project, the aim of this project is to support RACFs to embed within their routine clinical practice a comprehensive evidence-based palliative approach to care, thereby improving resident and family outcomes.
- Resources and Events Project, the aim of this project is to offer educational events and develop online educational resources for RACFs as a sustainable strategy to support ACP Champions and Palliative Approach Link Nurses in RACFs to provide quality end-of-life care to residents and their families.
Findings from our pilot project
The evaluation of phase one has been positive, most importantly with a demonstrated extensive improvement in ACP activity in participating RACFs. This is evidenced by the increased number of RACFs using the ACP document known as the Statement of Choices (SoC). This change means, that within participating RACFs, many more residents had the opportunity to express their end-of-life preferences and values thereby improving the opportunity for residents to receive care aligned with their preferences and values.
There was a system level change in participating RACFs’ ACP processes. Including an increased agreement with significant markers of evidence-based care such as in-service education about ACP, ACP discussions with residents and families on admission, educational material available for residents and families, review of deaths to assess if end-of-life preferences were met, and mechanisms for transferring ACP plans from the RACF to hospital.
ACP staff champions indicated a significant increase in knowledge, confidence and clinical skills necessary to undertake ACP discussions with residents and SDMs as a result of participating in the developed education.
Residents and SDMs considered it appropriate to hear about ACP while in the RACF, were satisfied with the way the topic was introduced and the amount of information provided, and considered that the nurse, who discussed ACP with them, cared about them. These findings from residents’ and SDMs’ surveys confirms the self-reporting from ACP champions that the program education resulted in increased clinical skills for initiating and holding ACP conversations. Residents and SDMs reported that hearing about ACP was not confronting. This is an important message for RACF managers, nurses and GPs as the literature reports that a major barrier to ACP discussions is the attitude of health care professionals.
Residents and SDMs also clearly stated that they preferred to hear about ACP from the facility nurse rather than the GP. This is another powerful positive message to disseminate to RACF managers and staff to support embedding ACP in clinical care within RACFs.
If you would like further information about this project please contact the Project Manager, Mia Taylen-Smith. email@example.com
Abbey, J. The reality for aged and community care and end of life. Presentation to A Matter of Life and Death: Confronting the New Reality. Canberra: March 2008.
Australian Government Department of Health and Ageing. Guidelines for a Palliative Approach in Residential Aged Care. Canberra: Rural Health and Palliative Care Branch, Australian Government of Health and Ageing; 2004.
Lund S, Richardson A, May C. Barriers to advance care planning at the end of life: An explanatory systematic review of implementation studies. PLoS One 2015. 10: e01116629
Palliative Care Australia. End of Life Care is everyone’s affair – tackling the challenge of ‘end of life’. Submission to the National Health and Hospitals Reform Commission. Canberra: Palliative Care Australia; 2008.
Productivity Commission. Introducing Competition and Informed User Choice into Human Services: Reforms to Human Services, Report No. 85. Canberra: Productivity Commission; 2017.
Mia Taylen-Smith, Nurse Practitioner, Metro South Palliative Care