Palliative Care in Residential Aged Care: Impact of Advanced Care Directives

This essay explores the provision of palliative care in residential aged care and critically evaluates the impact of advanced care directives (ACD) in residential aged care (RAC). Legal and ethical considerations associated with ACDs are also discussed.

Running head: PALLIATIVE CARE
Palliative care
Name of the student:
Name of the University:
Author’s note

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Introduction:
Palliative care is an approach to care that provides support to patients and families
with life threatening illness and offers a support system that reduces suffering and improves
the quality of life of such patients (Pal & Manning, 2014). With the increase in life
expectancy and the increase in ageing population, more number of elderly people is in need
of palliative care because of chronic multi-morbidity, frailty, functional dependence and
cognitive decline. Such trend has increased the demand for palliative care services that is
tailored to the needs and situations of the elderly and very elderly patients. As large number
of elderly people is now residing in residential care homes, the analysis of palliative care
services in RACs is necessary (Voumard et al., 2018). This essays aims to explore the
provision of palliative in residential aged care and critically evaluate the impact of advanced
care directives (ACD) in residential aged care (RAC). The essay will further look at legal and
ethical considerations associated with ACD and analyze strategies that may improve the
provision of palliative care in RAC.
Evaluation of palliative care in residential aged care:
The main purpose of palliative care services is to enhance the quality of life of people
with serious and life limiting illness and focus on providing aggressive symptom
management and psychosocial support to reduce sufferings for patients. It plays a role in the
alleviation of physical, psychosocial and spiritual symptoms of patient. Palliative care
specialists and other staffs working in palliative care services work to deliver appropriate
medical care and align patient’s preferences and needs with those of other team (Rome et al.,
2011). With the increase in ageing population, palliative care has been introduced in many
settings such as RACs, general community services and hospitals. The advantage of a
palliative care service in RACs is that they help to identify those patients who are in need of

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palliative care through Aged Care Funding Instrument (ACFI) assessment (Butler, 2017). The
key advantage of palliative care in RAC is that it gives elderly people the opportunity to
receive appropriate medical care from the comforts of their home. By reducing the need for
prolonged hospital stay, such palliative care services provide personalized care environment
to patients and reduce feelings of neglect, isolation and poor social support (Kong, Fang &
Lou, 2017).
As the number of RAC resident has increased, the decision regarding hospitalization
and end of life care has become more challenging for such residents. With the increase in
ageing population in Australia, the proportion of RAC resident has increased (Naccarella et
al., 2018). Although the provision of palliative care in RACs provide the benefit of reduced
hospital admissions and more symptom control, however some of the complex decision in
palliative care given in such facilities relates to hospital transfer decisions. Such challenges
emerge because of presence of disorders like dementia, advanced care directives and the
harms of hospitalization such as further deterioration of symptoms, pressure sores and
inconsistent care (Leong & Crawford, 2018). The report by Australian Institute of Health and
Welfare (2016) also justifies that RACs face challenges in administering palliative in patients
with co-morbidities and communication difficulties or dementia. For RAC residents,
separation from such facilities occurs in situations of death, admission to hospitals, returning
back to the community and other reasons. Future research needs to explore the manner in
which such decisions can be simplified and optimize safety for elderly patients.
Despite several issues associated with delivery of palliative care in RACs, the
popularity of the service cannot be ignored because of the role of such service in optimizing
quality of life for patients. Currently, minimizing hospitalization rate for elderly people in
RAC has become a focus of health care policy too. The care coordination between the nurse
practitioner and the multiprofessional health care team plays a role in providing better quality

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of life to residents. However, no change in rates of emergency department transfer has been
seen. The positive aspects coming out from such data is that the length of stays in hospital is
reduced for RAC residents receiving palliative care (Frey et al., 2018).
Critical discussion of advanced directives in residential aged care:
For patients receiving palliative care, one of the major challenges is faced for patients
who suffer from advanced level of disease such as cancer and those who are at the end of life
stage. Many time conflicts take place because a disconnection is found between end of life
care patients care preferences and what actually happens in practice (Ranganathan,
Gunnarsson & Casarett, 2014). To minimize such issues, the concept of advanced care
planning has emerged which allows people to plan ahead for their care preferences in case of
loss of decision making capacity in the future. This plays a role in respecting patient’s
preference as well as providing autonomy to patients during their care decision making
(Leditshke, Crispin & Bestic, 2015). During advanced care planning discussion, end of life
patients get the opportunity to share their cultural values, beliefs and care preferences to
guide future decision making. With regard to such planning, advanced care directive (ACD)
is prepared for individual patient, which is a special type of document where the advanced
care plan is expressed in writing and this is signed by competent adults and recognized by
common legislation (Ranganathan, Gunnarsson & Casarett, 2014). The prevalence of
advanced care planning among older people in RAC in Australia is high because of presence
of several legislation supporting the cause of patient autonomy. Such planning is particularly
important for elderly people as they are more likely to suffer from conditions impairing their
decision making capability (Street et al., 2015).
The main goal of advanced care planning and ACDs are to align the actual care
delivered to patient according to their preferences. Successful completion of ACDs supports

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palliative care staffs to get information about substitute decision makers for patient and
advocate for the patient’s preference during situations when the patient has lost his/her
decision making capacity (Pérez, Macchi & Agranatti, 2013). For example, in case of clinical
deterioration, many patients require cardiopulmonary resuscitation, oxygen tube or
antibiotics. By the use of the ACDs, RAC residents receiving palliative care are able to
express whether or not they want to receive that treatment in certain situations. Patients also
get the right to make changes in the ACDs any time and inform it promptly to their physician.
From the ethical point of view, the ACD is regarded as a document that preserves and
promotes patient autonomy. The use of ACDs among elderly people in RAC has the potential
to improve patient satisfaction with end of life care, minimize stress for surviving relatives
and manage uncertainties related to treatment options (Street et al., 2015).
Despite presence of legal directives on ACDs, the current challenge is that ACDs
have not been effectively utilized in palliative care. Some of the challenges associated with
ACDs are that many people change their preferences overtime. However, such change is not
recorded timely in their ACD (Street et al., 2015). Pérez, Macchand and Agranatti (2013)
gave evidence regarding another reason for barriers in effective use of ACDs by palliative
care staffs. The study gave the evidence that physician are uncomfortable with starting ACD
related conversation with patient as they feel it confronts the patient directly with the finitude.
This issue also reflects lack of communication related competency of palliative care staffs.
Another study revealed that ACDs are less frequently utilized by patients coming from
minority cultural and language background compared to the majority population. This has
been influenced by cultural values of patient. Time has also been identified as a barrier to
making ACD as such discussions require adequate time (Leditshke, Crispin & Bestic, 2015).
Because of the above mentioned challenges, the use of ACDs is limited and it is poorly
values by end of life patients. However, effective advanced care planning can be enhanced

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with proper appointment scheduling to complete the ACD and providing adequate training
regarding ACDs to palliative care staffs. Such training can facilitate incorporation of ACDs
in routine assessment and care planning for elderly people in RAC.
Legal and ethical considerations associated with advanced care directives in residential
aged care:
Legal challenges:
Based on the above discussion, it has been found that ACDs are less frequently used
by patients because of several obstacles and barriers in its effective use. Majority of such
barriers also arise because of legal issues in utilization of ACDs for different patient group.
For example, Detering et al. (2019) gives the evidence that lack of clarity regarding the legal
status of non-statutory ACDs is a legal challenge that reduce the confidence of many
clinicians and prevents them from actively following ACDs in palliative care. Australia is a
country where statutory legislation or common law recognizes ACDs. All jurisdictions in
Australia provide legal status to ACDs except New South Wales and Tasmania. However,
despite presence of such legislation, research studies demonstrate lack of actual
implementation of such documents in RACs. An assessment regarding experiences and
attitudes towards ACDS in RACs revealed that advanced care planning related practices were
inconsistent in the region and quality of the process varied too. The main cause behind such
inconsistencies included low confidence to undertake ACP related activities and variability in
the concordance between expressed care preferences and actual treatment provided (Silvester
et al., 2013). These concerns related to legal dilemma associated with advanced care planning
suggest the need to implement education related to ACP best practice initiative so that
clinicians embrace the document without any fear of criminal liability.

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The decision regarding going ahead with patient expressed preference in ACDs is also
challenged by the medical futility of the decision and the possibility of legal and professional
ramifications of the issue. Those favouring use of ACD argues that such documents are
useful in preventing use of medically futile treatment and empowering patients to deny
treatments that do not want (Hassan & Ali, 2018). However, as the order regarding
withholding interventions is given by the clinicians, it is essential that physicians are aware
about the principles of withholding interventions. This knowledge can save them from ethical
risk associated with adverse outcome after withholding treatment for patients. The decision to
go with DNR order of physician is also legally challenging decision. However, such legal
challenges can be confronted by the establishing the DNR status of patients at the end of life
(Galambos et al., 2016).
One of the process during completion of ACDs include patients acknowledgement of
substitute decision makers who will take decisions on their behalf in situations of loss of
decision making capacity. However, the legal dilemma associated with the involvement of
substitute decision maker is that there is lack of process regarding use of best practice
guidelines to ensure that substitute decision makers are aware of patient’s values and interest.
This creates the risk of a flawed decision that may increase risk for patient. A survey by
Mendoza and Burns (2016) regarding legal guardian involved in palliative care decision
revealed that less than half of them were aware about patient wishes. The study also
highlighted that patients often chose children or their spouse as decision makers. This raises
the question regarding the knowledge of substitute decision makers regarding the
consequences of implementing or withholding treatment. Hence, this issues emphasize on the
need for a shared decision model where treatment options and their risk and consequences are
clarified with families and treating physicians. This would eliminate any legal risk associated
with patient safety and risk to life for end of life patients.

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Ethical challenges:
ACD is regarded as important legal document that preserves the ethical concept of
patient autonomy. It gives patients the power to specific preferences regarding treatment to be
followed when their capacity is lost. However, ethical questions that doubts the utility of the
document in promoting patient autonomy is that no patients are competent enough to predict
their future and evaluate the benefits or utility of any treatment options. Their decision
regarding denying or accepting a treatment may not be always right (Bossaert et al., 2015).
On this ground, it can be argued that patients at end of life are not always competent to take
such complex case decisions. However, advanced care directive are found beneficial in
patients with certain disease that deteriorates their cognitive capacity with the progression of
the disease (Denniss, 2016). This can be explained taking the example of an elderly patient
with dementia. For dementia patient, cognitive competent is lost with time. Although they
can feel the pain and pleasure, however because of memory loss and cognitive decline, they
fail to express their actual interest and preferences. In such context, completion of ACDs is
found beneficial that preserved the best interest of patients and prevents violation of patient
autonomy.
Use of ACD in palliative care services invites many ethical arguments because of
conflict between the concept of autonomy and non-maleficence. This is said because ACDs
takes different forms such a living wills, health care proxies and do-not-resuscitated (DNR)
orders. It provides patient the scope to deny receiving invasive treatment like resuscitation
or blood transfusions (Peicius, Blazeviciene & Kaminskas, 2017). Though such decisions
fulfil the ethical value of patient autonomy while delivering care, it also creates risk for
patient because for certain patients, denial of such treatments may prove fatal too. Yu et al.
(2015) argues that such situation is an ethical dilemma for physicians because the physician is
faced with an ethical dilemma of using a recorded preference, which has been made with

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little knowledge of potential outcome of such preferences. Hence, for physicians who go
ahead with ACDs of eliminating treatment like resuscitation, they struggle to achieve a
balance between autonomy and dealing with unpredictable clinical events. They face the risk
of criminal or ethical liability too. This interferes with values of non-maleficence for patient.
However, many group defends the utility of ACD by stating that by having a completed
ACDs, physicians get the support to justify their decision to cease treatment. This
justification shows that instead of creating criminal or ethical risk, ACD is a useful document
that can provide clinicians good legal protection if it is completed in an effective manner
(Denniss, 2016).
Strategies to improve the provision of palliative care:
In the context of delivery of palliative care, ethical and legal challenges associated
with advanced care planning and ACDs are a major barrier that prohibits clinicians from
effectively using the document. For example, the risk of legal liability because of withholding
treatment has been identified as a challenge that prevents physicians from actively following
ACDs in palliative care. However, the confidence level of clinicians can be enhanced once
they are aware regarding the best practice guidelines to efficiently complete the ACD
document. Effective advanced care planning requires fulfilment of key process like
communication and documentation regarding preferences, consideration of different values
and care options, identification of substitute decision maker and enhancing access to such
documents to practitioners across different setting (Silvester et al., 2013). The process should
also be aligned to the needs of elderly clients living in RACs. This means while completing
the ACDs for individual patient, there is a need to focus on life goals, beliefs and values of
patient. The substitute decision maker should also be based on best interest of patient and
physicians must scrutinize the document to ensure that the ACD is valid and specific to the
situation at hand (Leditshke, Crispin & Bestic, 2015).

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Another strategy for improving the provision of palliative care in RAC is
implementing training programs that helps clinician to engage in appropriate documentation
related to ACDs and engage in clear discussion regarding ACDs with patients and the
involved health care team. Training can focus on improving communication skills regarding
death and future preference for treatment. This is particularly important because of evidence
regarding poor utilization of ACDs by physicians because of poor communication related
competency and the feeling of uncomfortable communication with patients. The key
advantage of communication related training is that it will allow physicians to be confident
and sensitive while speaking about end of life decisions and preferences with patient (Gigon,
Merlani & Ricou, 2015). Research study also gives evidence regarding the implementation of
the Physician Orders for Life Sustaining Treatment (POLST) program that is a tool that gives
physicians the opportunity engage in candid discussion regarding end of life care with
patients (Yu et al., 2015).
As the utilization of ACDs for elderly people receiving palliative care is associated
with many ethical issues related autonomy, beneficence, justice and non-maleficence, there is
a need to train physicians to preserve the rights of patients in all circumstance, even when
they have lost their decision making capacity. This can be done by increasing their
competence related to efficient use of advanced directives. In situations, where a physician
finds the ACD to be invalid and they doubt the decision making capacity of decision makers,
in such cases there is a need for physicians to advocate for approach that promotes good care
for patient. Any possibility of intentional harm should be avoided and they need to be faithful
to the dying patients (Arnett et al., 2017).
Summary:

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To conclude, the essay gave an insight into the provision of palliative care in RACs.
The essay justified the prevalence of palliative care services in RACs based on increase in
aging population and high cases of multi-morbidity in elderly patients. The discussion
revealed the provision of palliative care in RAC as important to enhance the quality of life of
patients at end of life and reduce the length of hospital stay. Advanced care planning is an
important component of palliative care and such legal documents gives patient at end of life
to express their preference related to treatment options before they become incompetent to
take such decision. However, the discussion regarding challenges associated with ACDs
revealed that lack of uniformity in legal provisions, poor understanding of implementing
ACDs, ethical dilemmas associated with ACDs and substitute decision makers and lack of
competence of physicians in effectively using ACDs as some major issues resulting in
improper utilization of ACDs. Considering the above challenges, the essay suggested the
need for training and education for physicians so that ACDs can be effectively implemented
to empower patients at end of life.

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