Analysis of Palliative Care in Residential Aged Care

This paper analyzes the provision of palliative care in residential aged care facilities, including evaluation, advanced care directives, and considerations. It discusses the political, philosophical, legal, and ethical issues associated with palliative care and provides strategies for improving care services.

Analysis of the palliative care provided by residential aged care
1

Table of Contents
1.0 Introduction..........................................................................................................................3
2.0 Evaluation of palliative care in residential aged care...........................................................3
2.1 Palliative care.......................................................................................................................3
2.2 Critique models in residential aged care..............................................................................4
3.0 Critical discussion of advanced care directives in residential aged care.............................4
4.0 Critical discussion of different considerations associated with advanced care directives in
residential aged care...................................................................................................................6
5.0 Strategies that may advance the provision of palliative care in residential aged care.........8
7.0 References..........................................................................................................................12
2

1.0 Introduction
Palliative care could be defined as the complete care facility for peoplediagnosed with
chronical life-limiting diseases.These patients are not capable of doing their daily tasks
without any support as the symptoms don’t allow them to. Palliative care centres provide all
facilities and care that are important to the residents according to the corresponding
diseasesthey have been diagnosed with. The care is equipped with experts and staffs who
have been well-trained about all the essential palliative care services offered by the resident
age care. These centres are mostly proving support to older patients for whom the disease is
fatal. These services focus on symptom management and making the lives of these people
less painful.
The following paper adopts analytical research approachfor palliative services that have been
provided with the residential aged care. In this paper, palliative care and the palliative
approach provided by the residential aged home has been discussed along with the political,
philosophical, legal and ethical issues that are prominent when providing the care services by
the facilities. Residential aged care service providers adopt various strategic outlines while
offering palliative care services and support. Therefore, recommendations for augmenting of
the services offered at the residential aged care have also been discussed in detail.
2.0 Evaluation of palliative care in residential aged care
2.1 Palliative care
Palliative health care support provided by the "residential aged care" encompasses various
supports and medical aid for patients suffering from end stage diseases. These care services
are developed as required by the residents. These care facilities work towards reducing the
pain that the patients go through due to the disease. Since these diseasesare fatal, the
palliative care at the residential aged care is responsible to take care of the symptoms and
making them less agonizing for the patients. These patients cannot stay at home as proper
care is not possible for the disease they are suffering from. These include chronic diseases
like cancer, AIDs, and advanced cardiac conditions. The symptoms relating to these diseases
and their treatment can be painful and cause distress to the patients. The residential aged care
institutions provide palliative care for such patients with expert staff and doctors available at
the centre. The residents at these care facilities can stay from a week or for a few years,
depending on the amount of care that is needed by them. Some residential care facilities also
provide special care for the residents who need it. This will help the residents be at ease, even
3

during difficult health conditions. The treatments and services provided by the residential
aged care are selected depending on the health report submitted before or during the
admission process. Only the palliative services that will help augment the quality of life and
provides necessary provision and medical aid to counter critical medical conditions will be
selected for the resident. (Frey et al. 2016)
The provision of palliative care is only for people who are at the last stage of their medical
condition by providing treatments that help make the symptoms less painful for the patients
staying at the facility. The main purpose of a palliative approach is to augment quality of life
that is offered to patients diagnosed with life-limiting illnesses by providing services and
treatments for pain along with fulfilling their psychological, cultural, spiritual and social
needs. Palliative approach is positive in nature that gives dying an open outlook. They work
towards providing comfort and treatments that help the resident reduce the intensity of the
symptoms that cause them distress. The palliative approach provides the resident and their
families with a sense of support throughout the process and help them with all the treatments
and care of the patients. The families can be at ease knowing that their loved ones are being
cared for and are not facing any kind of pain in their final moments. A need for palliative
approach arises when the residents become too dependable not only physically but also,
emotionally, spiritually and socially. The palliative approach is also used for people who are
dying due to the ageing process and not only the people who suffer from some kind of life-
limiting disease or have a weak mental health. Palliative approach has a positive outlook to
dying that work towards making the last moments of the patients peaceful and void of pain.
(Stokoe et al. 2016)
3.0 Critical discussion of advanced care directives in residential aged care
Advanced directives are planned at the beginning, during the admission of the patients to the
residential aged care. These directives hold information about the residents' preferences in
treatment and services in case an end-of-life event was to occur during the stay at the
residential aged facility. These directives are created not only for the older people but also
fairly younger residents in case there was an emergency. Therefore, every residential aged
care recommends people to have an advanced directive for themselves. An advanced
directive gives the residents the power to be in control of their treatment even when they are
not able to do so in case of an emergency. The advanced directives free the staff of the
burden regarding the decisions to be made in place of the patients. Advanced directives are
4

mostly legal documents that help in understanding a resident's last wishes. The main wishes
are about the comfort and pain control for the resident. (Leditshke et al.2015)
Advanced directives are of two kinds,
1. Living wills
Living wills are legal documents written by the residents that state their wishes
regarding treatment that the residents' want to use. The living will give the residents a
sense of independence and self-sufficiency. It is never too early to create a living will
as unexpected situations can occur at any point of time in life. Experts say that it is a
great step to follow before being admitted into the residential aged care. In case there
are no living wills or any other directives decided upon, the decisions are the default
that can lead to unnecessary transfers to different medical institutions and treatments
that the resident team does not approve of nor is the family okay with. (Sealy et
al.2019)
2. Medical Power of Attorney
A medical power of attorney is the person the resident chooses to make decisions for
them in the event where they are not able to make one on their own. Usually, medical
power of attorney is the spouse or parent or child of the resident or anyone whom the
resident believes in making the correct decision. (Regn et al.2016)
This is different from a power of attorney that is responsible for monetary or legal
matters. The medical power of attorney is only responsible for making choices related
to the health and welfare of the resident and nothing else. Even if one has already
arranged a living will, selecting a medical power of attorney is important because not
all situations will have been considered while creating it. (Dumanovsky et al.2016)
Choosing the correct person as the medical power of attorney is important and should
meet the following three criteria:
a. Is capable and willing to deliberate end-of-life issues and medical care
issues
b. A person who will make sure the wishes and values of the residents are
followed through
c. Will be able to keep the decisions a priority even if there are any issues
related to the case. (Picker et al.2016)
5

4.0 Critical discussion of different considerations associated with advanced care
directives in residential aged care
Advanced care derivatives allow individuals to plan for future care needs and personal care in
case of becoming unable to make medical decisions or being unable to communicate these
decisions. This allows an individual's likings and morals to be considered first in any medical
choices that have to be made. Residential aged care suffers from different issues related to the
political, philosophical, legal, and ethical aspects. Advanced care derivatives also have many
limitations. For example, they are limited to specific diseases and may not be enough to take
care of all the medical decisions of an individual. These derivatives are written long before
the patient is in any serious medical condition. Therefore, they may not have been written
with severe conditions in consideration. However, in such life-threatening situations, the
derivatives help the medical care givers and the patient's surrogate decision maker to make an
informed decision. (Giakoumidakis, 2017)
Political issues in residential care include:
1. Government Funding
Most of the palliative care facilities available are dependent on the government funding.
Therefore, the users do not have to pay a lot for the services just the basic minimal. However,
issues in residential care arise because the government policies regarding the funding of these
care facilities keep changing as the government changes. The funding fluctuates because not
all governments put the palliative care on the top of their priority lists. This results in the
fluctuation of the fees of the palliative care at the residential aged care (Butler, 2017)
Philosophical issues in residential care include:
1. Optimum care provided
The facilities should take proper care of the residents. Failure to do so will lead to
complications and disagreements within the facility due to which the quality of care
provided by the facility will deteriorate. This will in turn lead to deterioration in lives
of the patients causing them discomfort.
2. Racism and Sexism
There must be no barriers regarding the race and sex of the residents. All residents are
equally important and should be treated with the same amount of respect. The medical
staff should provide the residents with all their educational, cultural and spiritual
6

needs as will be mentioned in their advanced directives. These are the basis of the
palliative care along with symptom management. Patients and their families trust that
their cultures and spiritual needs are respected. In cases these are not provided, legal
actions against the facility can be taken by the families as the advanced directives are
legal documents.(Sudore et al. 2017)
The legal issues in residential aged care
1. Prescription laws
This can be defined as the prescribing medicines that are used to control symptoms in
the last days of life. This is called anticipatory prescribing. It includes consulting the
patient's family, writing the prescription, dispensing the medicines, and administering
the medicines to the patient. However, diagnosing when the patient is near death is
very difficult and can sometimes result in incorrect prescriptions. (Urden et al.2017)
2. Allow natural death
Allowing natural death is a legal term for Do Not Resuscitate (DNR). It is a legal
order which states that the patient does not want to receive CPR, advanced cardiac life
support (ACLS) or any other procedures in case the patient's heart fails, or the patient
stops breathing. This allows the patient to die naturally without any resuscitation of
any kind. The process and legal status of DNR differ from country to country. (Kim &
Choi, 2017)
3. Physician assisted suicide
It is suicide assisted by a physician or doctor. The physician's assistance is limited to
prescribing a lethal dose of drugs. However, it can only be done if the patient meets
the suicide laws of the concerned country. (Gomez-Batiste et al.2018)
Ethical issues in residential care include:
Even though care for an older person is complicated, if the relationship between the care
giver and the patient is proper, care can be appropriately given and without any problems.
Physicians are required to make decisions considering all the things related to the patient and
also consider the future needs of the patient. Working ethically; means that the patient's need
is placed first in all situations without any aggressiveness. The care givers should have an
7

ethical foundation and should find joy in taking care of the patients. The care givers cannot
be offensive and must maintain a proper relationship with the patient's family. The care
givers should respect the patients and accept an older adult's pace (Goligher et al.2017)
1. Informed Consent and Capacity
Ethics of informed consent is a useful piece of information to have during the time of
the patient's care. Substitute decision making is an essential notion for patients who
cannot take their own medical decisions. The right to informed consent is not a legal
artefact, but it is the fundamental ethical principle of society. It is a basic principle
which allows patients to make decisions for themselves after being informed of all the
risks and other such critical information. However, to exercise this right, the patient
must have proper decision-making capacity. (Beernaert et al.2016)
2. Autonomy
Autonomy means self – rule in Latin. The care givers must respect the decision made
by the patients regarding their health. It means that the care givers should not interfere
with the decisions made by competent adults nor should they influence the decision
made by the patient.
3. Beneficence
This principle states that care givers should do good for the patient. Doing good is the
best thing for the patient. It is defined as having a sense of kindness, mercy, and
charity for the patient and make any decision by keeping the patients’ best interests at
heart.
4. Nonmaleficence
This principle states that the care givers have an obligation of not harming the patient
in any situation. The patient should not even have a risk of being harmed by the care
givers. It is an ethical and legal duty of all caregivers to the patients.
5.0 Strategies that may advance the provision of palliative care in residential aged care
Palliative health care support provided by the "residential aged care" encompasses various
supports and medical aid for patients suffering from end stage diseases. These care services
are developed as required by the residents. Every case is managed individually, and there are
no specific plans for similar cases. Palliative care is provided by different facilities across the
whole world. There is no standard way of functioning for these facilities. They may differ
8

depending upon the region, health experts and residents admitted for palliative care.
Residential aged care suffers from different issues related to the political, philosophical,
legal, and ethical aspects. Though palliative care has advanced a lot over the period, there is
always a scope of advancement for these kinds of care. Palliative care relates to the treatment
of residents that are fighting chronic illnesses, and there is always a scope of advancement in
these facilities. (Liu et al.2017)
Different methods and strategies have been adopted by the residential aged care to advance
the palliative care provided by them. These mainly include the following strategies:
1. Must have a multi-disciplinary team for clinical care.
When deciding on the treatments that must be provided for the residents, members
that belong to teams of different disciplines and also from the palliative care team
must provide plausible inputs so that it becomes easier to understand the situation and
provide proper treatment for the resident. This strategy allows increasing
communications between the different teams that are included in the treatment and
have scheduled interactions between the multi-disciplinary teams. There will be a
sharing of information and evaluation of high-quality care plans becomes possible
that is beneficial for the patients' health and treatments. This also results in improving
relations between the different partners of the organization. (May et al.2016)
2. Agreements and plans should be formalized by having a written agreement.
When treating patients with chronic illnesses, there are often hospitals involved along
with the residential aged care that provides palliative care. Agreements between these
two communities must be formalized by having a written legal document stating the
partnership. This strategy will ensure commitments from both the sides and shared
responsibility of the patient. (Chan et al.2016)
3. Feedbacks from previous residents and their families
Receiving constant feedbacks about the services provided by the residential aged care
can help in improving the facilities offered. The current and past residents of the
facility can provide suggestions to the staff and depending on the importance and
feasibility necessary changes can be done at the residential aged care thus making
advancements in the services and treatments provided. The residential aged cares
cannot be fully prepared for every situation. Depending on the patients and the
9

treatments required by them, the facility can advance their treatments. Some people
have cultural and spiritual needs, which are offered at a few residential care facilities
and not all of them. Therefore, depending on residents' suggestion and feedback, the
facility can advance. (Meier et al.2017)
4. Upskilling of the staff at the residential aged care
The staff at the residential aged care must always be updated about the new
technologies that are provided and introduced in the different medical institution. This
process is called the upskilling of the staff. The residents and their families trust the
staff that has complete knowledge of the situation that the residents are in and will
have a peace of mind when they are sure that the life of the resident is in an expert's
hand. The residential aged care that provides an excellent level of palliative care is
only accessible, and no one will settle for anything less than a complete and fully
equipped care. (Schenker & Arnold, 2015)
5. Constant updating and advancement of processes
Different processes are followed by different residential aged care to provide
palliative care. These processes need to be continuously updated to keep the care
facility updated with the constant changes in the technology used for treatments. This
will ensure an increased level of efficiency and effectiveness in providing the
treatment to the residents of the residential aged care. (Greer et al.2018)
6. Multiple strategies for advancement.
Having only a single strategy to advance the palliative care provided is not as
effective. Therefore, it has been advised that providing multiple strategies for
advancement will prove to be beneficial for residential aged care. Combining the
different strategies will mean that advancements can be made not only in a single
discipline of palliative care but also having a concurrent updating and advancement of
the care provided at the residential aged care. (Mehta et al.2016)
Constant advancement in these services is possible by gaining continuous feedbacks and
suggestions about the services, updating the method of treatments as soon as new and better
methods are available and taking input about the treatments provided from multiple sources
for better care of the residents living at the facility.
10

11

7.0 References
Beernaert, K., Deliens, L., De Vleminck, A., Devroey, D., Pardon, K., Block, L. V. D., &
Cohen, J. (2016). Is there a need for early palliative care in patients with life-limiting
illnesses? An interview study with patients about experienced care needs from diagnosis
onward. American Journal of Hospice and Palliative Medicine®, 33(5), 489-497.
Boulanger, A., Chabal, T., Fichaux, M., Destandau, M., La Piana, J. M., Auquier, P., ... &
Salas, S. (2017). Opinions about the new law on end-of-life issues in a sample of french
patients receiving palliative care. BMC palliative care, 16(1), 7.
Butler, J. (2017) Palliative care in residential aged care: An Overview. Australasian Journal
on Ageing, 36(4),258-261
Chan, R. J., Webster, J., & Bowers, A. (2016). End‐of‐life care pathways for improving
outcomes in caring for the dying. Cochrane Database of Systematic Reviews, (2).
Dumanovsky, T., Augustin, R., Rogers, M., Lettang, K., Meier, D. E., & Morrison, R. S.
(2016). The growth of palliative care in US hospitals: a status report. Journal of palliative
medicine, 19(1), 8-15.
Frey, R., Boyd, M., Foster, S., Robinson, J., & Gott, M. (2016). What's the diagnosis?
Organisational culture and palliative care delivery in residential aged care in New
Zealand. Health & social care in the community, 24(4), 450-462.
Giakoumidakis, K., (2017). Advanced care directives as the core component of palliative care
in recipients of left ventricular assist devices. Nursing and Palliative Care, 2(5), 1-1.
Goligher, E. C., Ely, E. W., Sulmasy, D. P., Bakker, J., Raphael, J., Volandes, A. E., ... &
White, D. B. (2017). Physician-Assisted Suicide and Euthanasia in the Intensive Care Unit: A
Dialogue on Core Ethical Issues. Critical care medicine, 45(2), 149.
12

Gómez-Batiste, X., Blay, C., Broggi, M. A., Lasmarias, C., Vila, L., Amblàs, J., ... &
Quintana, S. (2018). Ethical challenges of early identification of advanced chronic patients in
need of palliative care: the Catalan experience. Journal of palliative care, 33(4), 247-251.
Greer, J. A., Jacobs, J. M., El-Jawahri, A., Nipp, R. D., Gallagher, E. R., Pirl, W. F., ...
&Temel, J. S., (2018). Role of Patient Coping Strategies in Understanding the Effects of
Early Palliative Care on Quality of Life and Mood. Journal of clinical oncology: official
journal of the American Society of Clinical Oncology, 36(1), 53-60.
Kim, D. J., & Choi, M. S. (2017). Life-sustaining treatment and palliative care in patients
with liver cirrhosis-legal, ethical, and practical issues. Clinical and molecular
hepatology, 23(2), 115.
Leditshke, I., Crispin, T., & Bestic, J. (2015). Advance care directives in residential aged
care. Australian Family Physician, 44(4), 186-190.
Liu, Y., Kline, D., Aerts, S., Youngwerth, J. M., Kutner, J. S., Sillau, S., & Kluger, B. M.
(2017). Inpatient palliative care for neurological disorders: lessons from a large retrospective
series. Journal of palliative medicine, 20(1), 59-64.
May, P., Garrido, M. M., Cassel, J. B., Kelley, A. S., Meier, D. E., Normand, C., ... &
Morrison, R. S. (2016). Palliative care teams’ cost-saving effect is larger for cancer patients
with higher numbers of comorbidities. Health Affairs, 35(1), 44-53.
Mehta, D. H., Perez, G. K., Traeger, L., Park, E. R., Goldman, R. E., Haime, V., ... &
Jackson, V. A. (2016). Building resiliency in a palliative care team: a pilot study. Journal of
pain and symptom management, 51(3), 604-608.
Meier, D. E., Back, A. L., Berman, A., Block, S. D., Corrigan, J. M., & Morrison, R. S.
(2017). A national strategy for palliative care. Health Affairs, 36(7), 1265-1273.
Patel, M. I., Bhattacharya, J., Asch, S. M., & Kahn, J. (2016). Acceptance of advance
directives and palliative care referral for veterans with advanced cancer: a retrospective
analysis. American Journal of Hospice and Palliative Medicine®, 33(8), 742-747.
13

Picker, D., Dans, M., Bailey, T., Heard, K., &Kollef, M. H. (2016). A14 ADVANCE CARE
PLANNING AND PALLIATIVE CARE: PATIENTS TO POLICY: Using The Early
Warning System (ews) To Identify And Establish Goals Of Care/advanced Directives In A
High Risk Patient Population: A Randomized, Prospective Trial. American Journal of
Respiratory and Critical Care Medicine, 193,
Regn, R., Robinson, W., & Robinson, W. R. (2016). The Inclusion of Palliative Care in
Initial Treatment Planning is Associated with Increased Utilization of Advanced Directives in
Women with Gynecologic Cancer. Gynecologic Oncology, 143(1), 216.
Schenker, Y., & Arnold, R. (2015). The next era of palliative care. Jama, 314(15), 1565-
1566.
Sealy, T., Tuttle, J., Gent, S., & Fawcett, R. (2019). 89 Specialist palliative care CNS support
service for care homes in south tees–development and review.
Stokoe, Amy, Carolyn Hullick, Isabel Higgins, Jacqueline Hewitt, Deborah Armitage, and
IanO’Dea.(2016) Caring for Acutely Unwell Older Residents in Residential Aged‐care
Facilities:Perspectives of Staff and General Practitioners. Australasian Journal on
Ageing 35(2)127-32.
Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., ... &
Kutner, J. S. (2017). Defining advance care planning for adults: a consensus definition from a
multidisciplinary Delphi panel. Journal of pain and symptom management, 53(5), 821-832.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2017). Critical care nursing: diagnosis and
management. Elsevier Health Sciences.
14