Guidelines for a Palliative Approach in Residential Aged Care

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6.10.1 Oedema of the limbs Assessment The limbs should be examined for any signs of swelling. Residents and their families can also indicate if they perceive that any limbs seem more swollen than normal. Assessment should include investigations to determine low albumin levels, which are associated with loss of protein. Management Oedema of the limbs can cause the resident, family members and carers concern, but there is sometimes little that can be done to resolve the swelling. Support for the family might include providing them with information on the causes of the oedema, as well as involving the family in using techniques that may yield some relief. Some of the suggested options could include [230] (Level EO): • elevation of the swollen limbs; • daily or more frequent washing (only if necessary); • minimal handling; • a bed cradle; • pain relief; • leaving limbs uncovered on water-resistant non-stick disposable sheets to protect bed linen (from weeping that may occur from the tissues in extreme cases); • massage (if the oedema is not extreme), as this might provide some relief for the resident — this can be provided by the family or a massage therapist; and • dietary interventions — depending on albumin levels, stage of the resident’s illness and/or ageing, and their preferences. 6.10.2 Wound care Assessment Careful assessment when dressings are changed is essential to identifying infection early. Other areas of assessment relevant to wound care should also be considered, such as pain. (See also Section 6.2, ‘Pain management’, for a brief discussion of incident pain and recommended use of analgesia for wound care.) Management Wound care specialists fulfil an important role as part of a multidisciplinary team as part of a palliative approach in RACFs. They can be consulted for their expertise; however, their services are generally limited to the more populated or metropolitan areas and hence they may be unavailable in rural and remote facilities. Guidelines for a Palliative Approach in Residential Aged Care 105
Wounds can occur in residents for a variety of reasons, such as immobility, inadequate skin integrity, trauma and malnutrition. The same principles for wound management in general health care are usually applicable to a palliative approach (see the Australian Standards for Wound Management .[231] However, when devising a treatment plan for wound care the central focus is the preference of the resident and/or their family. Residents in the terminal phase of ageing or illness may be unlikely to have wounds that will heal before they die, but care should remain attentive and be focused on ensuring their comfort. 6.10.3 Ulcers As it is anticipated that the aged care team will have a sound understanding of the assessment and management of ulcers, this will not be covered in this section. Should further direction be required, contact the Australian Wound Management Association. However, as nonpharmacological interventions are frequently used in the treatment or prevention of ulcers, the literature for this area has been reviewed and is provided below. Non-pharmacological management Systematic reviews of RCTs to assess the effectiveness of the use of therapeutic ultrasound [232] (Level I) and electromagnetic therapy [233] (Level I) in the treatment of ulcers found no evidence of these therapies being beneficial. Guideline: Skin Integrity 34. The use of high specification foam mattresses rather than standard foam mattresses can reduce the incidence of pressure ulcers. 35. The use of Australian Medical Sheepskins (natural not synthetic fibre) may be effective in reducing the incidence of pressure ulcers for those people who are at low to moderate risk of developing these ulcers. Ref No. Evidence level 226 I 226 227 I II 6.11 BOWEL CARE Bowel symptoms can affect a person’s sense of wellbeing and have a negative impact on quality of life. Bowel care is therefore a key component of a palliative approach [234] (Level QE). There is considerable variation in what are considered ‘normal’ bowel habits among older people. The bowel habits of each resident should be determined, rather than comparing one resident’s bowel habits to that of other residents. Faecal incontinence is associated with immobility, constipation, dementia and stroke for residents in RACFs [235] (Level II). Bowel changes can increase for residents receiving palliative interventions. The fundamental principles of bowel care in the palliative approach are ongoing assessment, prompt and individually tailored treatments, and minimisation of interventions that can cause loss of dignity. 6.11.1 Assessment Bowel assessment is an ongoing component of care in all RACFs. Because medications frequently used in a palliative approach can increase the risk of bowel symptoms, including 106 Guidelines for a Palliative Approach in Residential Aged Care
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Guidelines for a Palliative Approac
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NHMRC APPROVAL These guidelines wer
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4 ADVANCE CARE PLANNING 55 4.1 Impl
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16 MANAGEMENT’S ROLE IN IMPLEMENT
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17 Ann and Mr Wells’ family Helpi
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IMPORTANT NOTICE On 8 December 2005
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achieved for these guidelines from
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facets of a palliative approach are
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Additional levels of evidence The N
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Guidelines Ref No. Evidence level A
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Guidelines Ref No. Evidence Cachexi
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Guidelines Ref No. Evidence Anxiety
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Guidelines Ref No. Evidence 70. Und
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1.1.1 Aims The aims of the systemat
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Table 1: Search terms Terms Aborigi
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1.1.5 Exclusion Criteria Although t
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in the methodology that may invalid
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To ensure the reliability of the re
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1.2.2 Methodology When the first re
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1.4.2 Method When feedback was requ
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Several Working Party members conve
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or disagreed with each stakeholder
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All the feedback received was colla
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CHAPTER 2 A PALLIATIVE APPROACH A s
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• Profound weakness • Trouble s
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• Has the resident had a recent d
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in the RACF rather than transferrin
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palliative care teams is more appro
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or ageing progression (see Table 4)
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Table 7: A practical model of socia
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Vignette 2: Robert’s story Robert
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Page 70 and 71: efore discussing the advance care p
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Page 74 and 75: CHAPTER 5 ADVANCED DEMENTIA Advance
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Page 78 and 79: 5.3.2 Acute illness One study found
Page 80: Vignette 5: Anna’s story Anna was
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Page 87 and 88: Table 8: Common myths about pain ma
Page 89 and 90: 6.2.4 Breakthrough pain The term
Page 91 and 92: Pain can lead to behavioural change
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Page 101 and 102: The reasons for malnutrition in old
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Page 105 and 106: To assist in such a discussion, a d
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Page 109 and 110: Guideline: Hydration 24. Recommenda
Page 111 and 112: 6.7 NAUSEA AND VOMITING Nausea is t
Page 113 and 114: • Do you have any problem control
Page 115 and 116: 6.9.1 Assessment A thorough oral as
Page 117: 6.10 SKIN INTEGRITY The major skin
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Page 123 and 124: medication treatment along with non
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Page 130 and 131: CHAPTER 7 PSYCHOLOGICAL SUPPORT A r
Page 132 and 133: 7.1.1 Death statements and depressi
Page 134 and 135: the factor structure of the CSDD. I
Page 136 and 137: 7.2.2 Management Non-pharmacologica
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Page 140: is recognised that in many rural an
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Page 145 and 146: 8.4 FAMILY INVOLVEMENT The role of
Page 148 and 149: CHAPTER 9 SOCIAL SUPPORT, INTIMACY
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Page 154: Guideline: Social Support Social Su
Page 157 and 158: include lack of information about t
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Guideline: Spiritual Support 68. A
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interpersonal and leadership skills
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CHAPTER 14 END-OF-LIFE (TERMINAL) C
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mood (61%), constipation (59%) and
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e relevant, and may even worsen sym
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Treatment involves changes in posit
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14.5 PREPARING FOR IMMINENT DEATH
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education of the aged care team and
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Table 21: Grief, loss and bereaveme
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• excessively avoiding tasks remi
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Vignette 18: Reflections When provi
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may have been able to contribute to
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CHAPTER 16 Management’s role in i
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REFERENCES 1. World Health Organiza
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31. Hanson, L. C., Danis, M. & Garr
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60. World Health Organization Quali
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89. McCarthy, M., Addington-Hall, J
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121. Saunders, C. M. (1998). Forewo
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150. Sindrup, S. H. & Jensen, T. S.
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177. Berry, E. M. & Marcus, E.-L. (
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208. Robinson, S. B. & Rosher, R. B
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237. Brocklehurst, J., Dickinson, E
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265. Barraclough, J. (1997). ABC of
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295. Brown, T. M. & Boyle, M. F. (2
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328. Kristjanson, L. J., Leis, A.,
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360. McGrath, P., Vun, M. & McLeod,
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392. Saunders, C. M. & Baines, M. J
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424. Rawlings, D. & Glynn, T. (2002
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Glossary acetaminophen Acetaminophe
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coordinator of volunteers coping A
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geropsychologist A geropsychologist
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opioids Opioid is a specific term u
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specialised palliative team A speci
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Ms Wendy Shiels Dr Jane Sims Dr Chr
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APPENDIX B The Australian Governmen
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APRAC GUIDELINES: EVIDENCE EVALUATI
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APRAC GUIDELINES: EVIDENCE EVALUATI
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APPENDIX F: Summary of the frequenc
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APPENDIX G: An example of how the g
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APPENDIX I: Resource list PALLIATIV
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Psychological Challenge Depression
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APPENDIX J: Examples of advance dir
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Schedule 1 MEDICAL POWER OF ATTORNE
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APPENDIX K An example of a Genogram
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INDEX Abbey Pain Scale 64, 71, 78 A
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evidence levels 5, 6, 20, 21, 22 ev
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andomized controlled trials 5, 21 R
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Palliative Care Australia PO Box 24
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Guidelines for a Palliative Approach in Residential Aged Care

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