Palliative care is primarily about quality of life. Guidelines for implementation of the new Aged Care Quality Standards, which will come into effect in July 2019, state that “the consumer’s right to make informed choices, to understand their options, and to be as independent as they want, all affect quality of life.” These include each person’s choices about the care they will receive as they approach the end of their life.
A paper published in 2014 by the Grattan Institute, Dying Well, noted that, whilst between 60-70 per cent of Australians would prefer to die at home, currently 32 per cent die in aged care facilities and a further 54 per cent in hospitalsi. Whilst it is not usually possible for residents of aged care facilities to return to their home to die, it is certainly preferable that they are able to live their final days in comfort and with dignity in the familiar surroundings of their room in the facility, in the company of those they love and being cared of by staff they know. Clearly, hospitalisation in the last days or weeks of life needs to be avoided unless that is the expressed choice of the resident or it is not possible to maintain their comfort and dignity in the home.
Shortly after the release of the Grattan Institute’s findings, Eldercare revised its palliative care procedures to ensure that residents were not being admitted to hospital in the terminal stage of their life unless that admission was their choice or considered necessary to maintain comfort and dignity. This revision resulted in the implementation of the Palliative Approach in Residential Aged Care (the Palliative Approach)ii across our facilities. The Palliative Approach offered Eldercare an evidenced-based framework of key processes enabling a multidisciplinary focus on advance care planning, ongoing assessment and effective symptom management. The desired outcome was well-planned palliative care that enabled quality of life, comfort and dignity for each resident from admission to death. Of added benefit for our care teams was the easily accessible resources in the Palliative Approach Toolkitiii courtesy of CareSearch, which made the Palliative Approach easier to implement ‘off the shelf’.
Eldercare’s application of the Palliative Approach allows a multidisciplinary collaboration in the planning and delivery of care. It places the resident at the centre and involves their representatives and their general practitioner working in partnership with Eldercare’s clinical and care teams as well as Chaplaincy and Lifestyle staff. Care planning encompasses the clinical, emotional, psychosocial, cultural and spiritual needs of each resident. Our goal is to deliver peace of mind, for residents and their families, derived from an assurance that comfort and dignity will be at the forefront of our approach to end of life care and that, as far as reasonably possible, each resident’s choices will be noted and honoured.
Site-based multidisciplinary teams (comprising clinical leaders, chaplains, Lifestyle and allied health staff) meet to conduct six-monthly care plan reviews for each resident. Assessing which of the Palliative Approach trajectoriesiv best describes each resident’s estimated prognosis is integral to the focus of these multidisciplinary care plan reviews. This assists staff to adjust care plans to include key palliative care processes for each trajectory.
Eldercare has Chaplains based at each site who are available to residents and their families to provide emotional and spiritual support in end of life conversations, in experiences of grief and loss and when a resident is dying. Chaplains also ensure that residents’ and families’ religious and cultural choices related to death and dying are honoured. In this way, Eldercare seeks to offer a holistic, empathic and inclusive approach to palliative care.
The implementation of the Palliative Approach has had a beneficial impact on the end of life care of our residents at Eldercare. Far fewer residents are dying in hospital or being admitted to hospital in the last week of their life than was the case prior to the implementation of the Palliative Approach. The use of the Residential Aged Care End of Life Care Pathway (a key process in the Palliative Approach) has improved the confidence of staff in providing timely and consistent palliative care, where symptoms are managed effectively ensuring comfort and dignity are maintained. Residents and their families are expressing appreciation for the opportunity to have meaningful conversations with staff about their end of life choices knowing that those decisions will be noted and treated respectfully.
i Swerissen, H and Duckett, S., 2014, Dying Well, Grattan Institute, p29
ii Australian Government, NHMRC, 2006, Guidelines for a Palliative Approach in Residential Aged Care