Care Planning

Professional standards for nurses stipulate that all nursing care is based on thorough assessment of needs and is evidence-based. Both nursing standards and Aged Care Accreditation Standards require that the recipient of care (or representative) is involved in the care planning process.

Planning care

Planning care to meet the palliative care needs of residents has three aspects. However as many residents are now admitted in the final weeks of life, for many residents these aspects may be compressed into one or two care planning episodes.

1. Anticipating and identifying needs at some further point for residents who are not expected to die soon

Ideally this begins before admission, continues through the admission process and the resultant plan is reviewed and updated at regular care plan reviews or when there is a change in the residents health. This may be referred to as Advance Care Planning (ACP).

2. Implementing a palliative approach to care for residents for whom death is likely within the next 6 months

This includes a review of care needs and previous ACP with resident, family, staff, GP and allied health professionals caring for resident. A new plan consistent with revised goals of care and managing identified needs is then implemented.

3. Implementing an End-of-Life Care Plan (EoLCP) for residents for whom death is likely within days or weeks

Care for residents at the end-of-life should be reviewed frequently. The focus is on symptom control and supportive care of resident and family. It includes care at time of death and immediately after.

Advance care planning is supported by:

  • Advance directives
  • Other documents indicating resident’s wishes
  • Open communication between facility staff, resident and /or substitute decision maker
  • Sensitivity to cultural needs
  • Staff with high level communication skills and confidence in approaching end-of-life discussions with residents, families and other members of the health care team
  • Organisational commitment to advance care planning with education and systems that support routine use of ACP, by staff.

Advantages of advance care planning:

  • Resident’s wishes are identified and respected
  • Resident and or substitute decision makers are involved in decisions about care
  • Fosters understanding and support between resident, family and health care team
  • Cultural, spiritual and emotional care needs of resident can be identified and supportive measures implemented
  • The needs of resident and family for information about end-of-life care, bereavement, palliative care support that the RACF can offer can be identified and addressed.

An advance care plan is unique to each resident, it should include the following (where appropriate):

  • Preferences for resuscitation, CPR, comfort care, hospital transfers
  • Preferred place of death - RAC, hospital, home
  • After death care - funeral director, preference for cremation or burial, cultural practices
  • Does the resident have a pacemaker?
  • If the resident has a pacemaker, does it defibrillate, and if so what discussion have they had with physician about when that function may need to be turned off?
  • Who has authority to make decisions about care if the resident is unable to? The contact details of decision makers
  • Spiritual and Religious care needs. Contact details of spiritual and religious adviser(s).

Implementing a palliative approach:

  • May include a case conference to confirm goals of care and to revise care plan
  • Aims to effectively manage symptoms, to allow resident to live comfortably until the end
  • Requires clear communication to all caring for resident of current care needs and how they are to be met
  • Has a focus on social, emotional and spiritual care needs of resident and family
  • May provide evidence to support an ACFI claim for increased funding to meet palliative care needs.

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Last updated 30 January 2017