Analytical Report on Palliative Care in Residential Aged Care Settings

This report analyzes current issues associated with delivery of palliative care in residential aged care settings, including types of care, advanced care directives, and strategies for improvement.

Analytical Report
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Introduction
Palliative care in Australia is defined as a group of approaches that improves the
quality of life of patients and their families facing life-limiting illness, through prevention and
relief of suffering (Australian Institute of Health and Welfare [AIHW], 2018). This can be
done by means of early identification, assessment and treatment of pain, other physical
problems, psychological issues and spiritual distress. While delivery of palliative care is not
the primary role of residential aged care facilities, they are well suited to delivery of such
services. Residential aged care is designed for older people who can no longer live at their
home. This kind of services provides round the clock support to older adults like the
accomplishment of daily living activities and personal care (AIHW, 2018). The Victorian
State Government (2019) highlights that for terminally ill patients such as cancer patients,
procurement of palliative care under the residential aged care settings is of prime importance.
The following report will analyse current issues associated with delivery of palliative
care in residential aged care settings. The report will start with a detailed explanation of
palliative care provision in residential aged care settings. This will be followed by a critical
analysis of advanced care directives in residential aged care and strategies to improve the
overall provision of palliative care in residential aged care settings. The report will thus help
to increase overall understanding of contemporary issues associated with aged care and
appropriate strategies to improve the quality of healthcare service delivery in aged care.
Palliative care in Australia
With the aging population in Australia, an increasing proportion of people are older
than 75 years and there has been an increase in chronic and incurable diseases ((AIHW,
2018). Thus the need for palliative care for elderly patients has increased (AIHW, 2018). In

2015 to 2016 more than 73,900 hospitalisations in Australia were for palliative care services
(AIHW, 2018). Palliative care service delivery must adapt to the increasing needs.
The Australian population receive palliative care services on the basis of need and not
on the prognosis (AIHW, 2018). In Australia there are almost 1.1 million cases of cancer
related hospitalizations during the tenure of 2016 to 2017. Of them 3.4% (36133) of the
patients were admitted to the palliative care unit. In other words it can be said that palliative
care services are mainly dominated by cancer patients, with 30.7% of pancreatic cancer
patients, 27.4% of lung cancer patients and 20.8% of brain cancer patients. The reasons for
fast deterioration among the cancer patients and they admission to the palliative unit is stroke
(4.2%) and sepsis (3.7%).
Considerable effort has been made to ensure that Australians with life-limiting
illnesses are provided the level of care they need. The lowest intensity of palliative care that
can be provided in any settings is delivered by secondary health care provider after being
referred by primary health care providers. After this, specialist palliative care services are
divided into three categories: resource level 1 is low-intensity care that can be provided with
limited resources at home like relief from pain through pharmacological or non-
pharmacological interventions along with social, emotional and cultural support. Level 2
specialised care is medium intensity and is of higher intensity than level 1 and generally
offered in metropolitan and regional centres; and level 3 is otherwise called high-intensity
care. It is advanced in comparison to level 1 and level 2 (Palliative Care Australia, 2018). It is
usually provided in large regional centres like providing external supply of oxygen, nutrition
through naso-gastric tube and monitoring of the vital parameters with the help of pulse
oxymetry. It requires advanced setup. Primary healthcare providers (mostly general
practitioners) have authority to refer patients to all the three levels of palliative care
depending on the client’s needs (Palliative Care Australia, 2018).

Palliative care in residential care settings
Most older adults who are terminally ill or have chronic illness live in residential aged
care. Thus palliative care in residential aged care settings holds great potential to meet
increasing needs. This is mainly provided by primary healthcare providers such as general
practitioners and registered nurses. Primary healthcare providers who deliver palliative care
in residential aged care services are regulated under the Aged care Act of 1997 and governed
by the Quality of Care Principles (AIHW, 2018). Under the schedule of specified care and
services an Approved Provider of residential aged care services is mainly responsible for
giving access to a palliative care team and subsequent establishment of a palliative care
program. This program deals with monitoring the effectiveness and managing side effects of
palliative care treatments in residential aged care residents while ensuring comfort and
dignity (AIHW, 2018).
Types of palliative care in residential aged care settings
According to the Guidelines for a Palliative Approach in Residential Aged Care
(2004), there are three forms of palliative care that can be delivered in residential aged care
settings in Australia. The first is called the palliative approach. It is appropriate when the
condition of the resident is not amenable to cure and the disease symptoms demand effective
management of the symptoms. The main goal of palliative care approach is to improve the
level of comfort of the resident along with functioning in order to satisfy their psychological,
spiritual and social needs (Australian Government Department of Health, 2009).
The second type of palliative care services provided residential aged care setting is
known as specialised palliative service provision. This involves referral to a specialised
palliative care team or specialised healthcare practitioner. However, it cannot be regarded as

a replacement for the palliative care approach. Rather, it requires focused, intermittent and
specific input as required. The main goals of this specialised service are assessment and
treatment of complex symptoms experienced by residents of the aged care with life-limiting
illnesses and providing appropriate information and advice on complex issues like family
issues, ethical dilemmas, psychological issues and external distress. The advice is mainly
given to the aged care teamto assist them in the day-to-day management of specific patients
(Australian Government Department of Health, 2009).
The third form of care is known as end-of-life or terminal care. This type of
palliative care is suitable for residents who are in their final weeks or days of life. At this
stage, care decisions need to be reviewed more frequently. Goals are strictly focused on
physical, emotional and spiritual well-being of the resident and mental health support may
alsogiven to the family members. Proper identification of when the resident is progressing
towards the terminal phase assists the residential aged care team to provide appropriate care
and communication. This can be difficult as there are few indicators for the identification of
the stage. It becomes more difficult when the resident has more than one disease. It is the
duty of the aged care team to carefully consider these factors, discuss with family members
and to respect the choices of the patient and family members in the domain of treatment
options. When managing this phase, it is important to provide information to family members
in a proactive way and develop a partnership with the family members (Australian
Government Department of Health, 2009).
Advanced care directives in residential aged care
Advanced Care Directives (ACDs) are an important tool for advance care planning,
enabling people to plan for their own future healthcare and for personal needs if they
experience difficulty communicating their needs. An advanced care planning discussion gives

provision to a person's individual values, beliefs and preferences to guide their future
decision-making process and help generate a written format of the advance care plan.
TheACD is a formal palliative or end-of-lifecare plan expressed in writingby an adult who is
recognised as a competent individual under common law or legislation and signed in front of
a solicitor. The treatment and clinical care plans written by the healthcare professionals are
informed by advance care plans(ACPs) and ACDs(Crispin, Bestic&Leditshke, 2015).
Figure: Russian “doll” model of ACDs and ACPs
Source: Australian Health Ministers Advisory Council.
A National Framework for Advance Care Directives. Canberra: MHMAC, 2011
Ethical aspects of the ACDs and the complications
Several principles guide ethical practice for establishing and implementing ACDs.
The core ethical principle is respecting each person’s autonomy. This principle defines that a
competent person is an autonomous individual and has an equal right to make his or her own
decisions in the domain of personal and health matters (Crispin, Bestic & Leditshke, 2015).
Autonomy under ACDs can be implemented in different ways depending on a person’s
culture, spiritual and religious beliefs and background (Crispin, Bestic & Leditshke, 2015).

However, Xiao et al. (2017) highlighted that the majority of the residential aged care services
lack proper support of a culturally competent or Aboriginal workforce. This creates a gap in
the framing of person-centered culturally competent care plans based on clinical priority, and
thereby breaches the patients’ right to autonomy.
The right to autonomy requires patients to have the ability to communicate their
wishes. Kellyet al. (2018) reported that the majority of residential aged care services offering
palliative care lack speech-language pathologist. A person who has special communication
needs cannot be considered as a person who lacks the capacity to take part in decision making
processes. Older adults receiving palliative care following a stroke or for cardiovascular
problems often experience difficulty in communication. The lack of a speech-language
pathologist creates a barrier to ascertaining the wishes or gap in knowledge of the person with
the communication problem, thus breaching the ethical principle of autonomy under ACDs.
The concept of autonomy also gives importance to informed consent that is giving
consent for a particular therapy plan. A study conducted by Tattersall (2017) stated that at the
time of the informed consent it is never possible for the palliative care professionals to
discuss all the potential endpoints of the therapy. Such endpoints could include a nil-by-
mouth recommendation, the requirement for tube feeding or assessment through fluoroscopy
or endoscopy. It can be difficult to meet the ethical principle of autonomy during the
informed consent process prior to conducting a clinical assessment. The list of possible
outcomes could be very long and overwhelming the patient.
ACDs generally give rights to a family member or other competent person to support
and make a decision on behalf of the residual decision maker when he or she is found
incompetent. This right is opted by giving power of attorney. The decision of the substitute
decision maker should only be based on the interests of the client (Crispin, Bestic &

Leditshke, 2015). It can be difficult to ascertain whether the primary care receiver is
incompetent to take an active part in the decision-making process,especially when patients
suffer from multiple illnesses (Kolva et al., 2014). Clinicians working with terminally ill
patients often fail to adequately assess the capacity of clients to take part in the decision-
making process (Kolva et al., 2014).The underlying reason is generally lack of proper
knowledge of the clinical to access the level of decision-making skills of the service users
(Kolva et al., 2014). The residential care system also lacks a comprehensive approach to
helping the healthcare professionals in their responsibility to balance the respect of the patient
autonomy and their responsibility to refrain from harming patients resulting from the
impaired decision-making capacity (Kolva et al., 2014).
Under ACDs, clients receiving palliative care may refuse to avail certain health-
related interventions, and such circumstances must be monitored carefully (Crispin, Bestic &
Leditshke, 2015). In some instances, refusal of palliative care therapy has been found to
decrease the overall quality of life and well-being of the individuals. For example, patients
with metastatic non-small cell cancer (NSLC) refusing to undertake the palliative therapy in
residential aged care settings have been found to have poor survival (Stavas et al., 2015). The
refusal of palliative care therapy triggers the requirement of integrating palliative care
services and thereby hindering the intellectual harmony of both the patient and the family
members (Stavas et al., 2015).
Strategies to improve the provision of palliative care in residential aged care
Education of staff working in residential aged care settings
Improving the quality of life of the people in palliative care demands a proper
understanding of the client’s needs in a diverse range. Cancer is one of the prevalent illnesses
managed by palliative care, followed by neurodegenerative conditions such as dementia,

cardiovascular complications, and musculoskeletal diseases. The median length of stay in
palliative care provides an important context to the level of care along with the needs of the
person. In other words, it can support people in the residential palliative care systemto have a
greater degree of needs and thus constant education and training of the healthcare
professionals and the nursing staffs is important (Butler, 2017). Brownie and Nancarrow
(2013) have stated that culturally competent nursing workforce can be produced under the
promotion of the trans cultural nursing practice and at the same time creating provision for
the recruitment of the Aboriginal and CALD nursing workforce. A culturally competent team
in aged care helps to meet the psychological needs of the older people that are
culturallyconsistent. A culturally and linguistically diverse team promoted effective
psychological interactions and thereby facilitating the overall provision of care(Xiao et al.,
2017). A culturally competent workforce will help to implement a person-centered
intervention that is multifactorial. The main factors of this intervention will include creating
opportunities for social stimulation and interaction, environmental enhancement and
empowerment of the patient (Brownie &Nancarrow, 2013).
Updating residents and families about ACPs before and at the time of admission
The intended progress and potential outcomes of palliative care therapy in the
residential aged care environment must be discussed with patients and family members in a
periodic manner. This process must be commenced by conducting an interactive session with
the families and the patients (Aasmul, Husebo & Flo, 2018). In order to initiate
communication with the patients and their family members, healthcare professionals must be
trained in the domain of interpersonal communication skills or effective communication
skills. This includes both verbal and non-verbal communication skills. Use of the verbal
communication skills like active listening and maintenance of proper body language among
the health care staffs help to promote the patient engagement and thereby helping to develop

therapeutic relationships(Harris et al., 2016). The development of therapeutic relationships
besides providing help to access the clinical priority also increases the degree of therapy
acceptance among the patients. This particular on effective communication skillswill
benefitthe healthcare professionals to overcome the fear of initiating the communication in
the domain of the end-of-life issues and thus preventing unwanted delay(Greer et al., 2016).
Moreover, Aasmul, Husebo, and Flo (2018) assured for proper implementation of the nursing
leadership in order to encourage the nursing professionals to indulge in effective
communication with the patients and their family members.
Topics that must be discussed
The topics of conversation with the patients and the family members must encompass
the domain of living-well and raise the issues of life-prolonging treatment without focusing
on any specific type of treatment. It is also recommended to engage the patient’s general
practitioner in the conversation with the family members in the ACP (Towsley, Hirschman &
Madden, 2015).
Proper patient documents
Appropriate and accurate patient documentation reduces the risk of errors in therapy
delivery and also helps in the development of culturally competent and person-centered care
plans (Detwiller & Petillion, 2014). Residential aged care services must document the name
of the substitute decision maker where applicable, along with the current state of health of the
patient, the cultural and spiritual values and beliefs and wishes for managing future health
conditions. Documentation must also include the level of the preferred treatment if indicated
by the general practitioner, signed by the patients and family members in the presence of the
doctors. In addition to appropriate record keeping, an effective information transfer system
must also be present in the residential aged care setup to enable communication of the
advance care planning information to the other healthcare providers (Kerr & McKinlay,

2013). Proper documentation of the patient’s information and effective navigation of that
information within the healthcare team can be achieved using electronic healthcare records
(EHRs) along with training of the nursing professionals to handle the data excavating in
EHRs while ensuring privacy and confidentiality (Holup et al., 2013).
Conclusion
Thus from the above discussion, it can be concluded that the palliative care in
residential care settings is an important aspect of palliative care delivery. The main goal of
palliative care in residential aged care settings is to improve the overall quality of life of the
individuals by reducing the degree of pain and suffering. It is the duty of healthcare
professionals to provide palliative care under the strict ethical guidelines of patient autonomy
and informed consent. However, inadequate training of healthcare staff in residential aged
care settings creates a barrier in implementing person-centered approaches to assessment of
patient competency to provide informed consent. In order to improve the overall quality of
care provision, healthcare professionals working in residential aged care settings should be
trained in cultural competency and more Aboriginal healthcare workers should be recruited.
The installation of EHRs will also help to increase the overall process of documentation and
help to work as per the patients’ cultural, spiritual and clinical needs.

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