Planning - Attendance

It is important that input is gained from a range of perspectives and disciplines. Attendance will vary based on the skill mix of staff available and the clinical situation. Disciplines relevant to developing strategies for the management of behavioural and psychological symptoms of dementia for example could involve an occupational therapist, diversional therapist and care assistance staff to identify activities that are manageable day to day.
Attendance by care staff who provide regular care to the person are able to provide valuable insight into changes in the person’s status and are extremely valuable in discussions with family.

Attendance should include:

  • One or more family members, friends or guardians with authority to make decisions about the person’s care and others with insights and interest in the person’s needs
  • A case conference facilitator to chair the meeting , ensuring that all agenda items are addressed and everyone has an opportunity to participate
  • Where the facilitator does not have authority, a more senior staff health professional who can ensure any agreed care plan can be put into practice
  • Registered nurse(s) with clinical expertise and experience to inform decisions about medical care
  • Care Assistance staff (e.g. AINs, personal carers) who know the person well and can provide current advice on the person’s individual strengths and needs. These staff often provide essential information about the person’s current health and functioning at all times of day and night that even the family may not be aware of
  • General Practitioner – where there are concerns about clinical changes, including medications and to ensure the GP, family and staff are “on the same page” about end of life care.  Their involvement can also assist in the development of palliative care plans, decisions about hospitalisation or artificial feeding, and the management of changed behaviours.
  • Other health professionals with specific expertise as required by the individual person with dementia’s needs. This may commonly include allied health personnel, specialist palliative care and geriatrics health professionals, and pastoral care providers.
  • Consideration should be given to including the person with dementia in the case conference. Even if they are not competent to make decisions, their input provided by both verbal and non-verbal means can contribute to an understanding of what their wishes may be. The person’s presence may also serve as a reminder to health professionals to focus conversation on their individual needs. 

Attendance may also include:

  • Aboriginal health workers
  • Aged Care Assessment Team
  • Chaplains/pastoral care workers
  • Dietician
  • Discharge Planner
  • Generalist nurses (RN and EN)
  • Geriatrician
  • Link nurse
  • Occupational therapist
  • Complementary therapists
  • Palliative care physician
  • Pharmacist
  • Psychologist
  • Psycho-geriatrician
  • Physiotherapist or physio aid
  • Podiatrist
  • Speech Pathologist
  • Specialist nurses (aged care, palliative care, wound care)
  • Others as needed to provide expert advice or who are invited by the family
Last updated 14 October 2015