Guidelines for a Palliative Approach in Residential Aged Care

9.2.2 Management
Imaginative programming and provision of leisure pursuits in RACFs leads to many and
various opportunities for social contact between the aged care team, residents and families, as
illustrated by the following story.
Vignette 11: The masquerade ball
It was the evening of the masquerade ball. The facility’s lounge was a blaze of colour, the
musicians were playing and the wheelchair dancing commenced. Ethel and Doris were
sitting together, their respective husbands too ill and frail to join the festivities. Ethel and
Doris, each in her early 80s, visited their husbands daily, returning to their empty homes,
experiencing the emotional and physical impact of ‘pre-widowhood’. “Would you like to
dance?” one of the aged care team asked Ethel. “Who, me?” Ethel replied, overcome by
surprise. Linking arms, staff member and relative danced to the old tunes, Ethel flushed
with excitement and stimulated by her memories. “Do you know, Fred and I used to go
dancing every Saturday night? Since his stroke, we’ve never even been able to embrace.
I think that’s the first time anyone has put their arms around me for months. Thanks so
much.” Doris plucked up courage to join hands with a male resident in a wheelchair. Joe,
usually passive and uncommunicative, tapped his feet as Doris twirled him around, daring
to give him a hug at the end. “Thanks for the dance”, she said. Joe seemed to grow taller
and straighter in his chair, beaming a rare smile.
Although there needs to be a positive acceptance of residents’ need for intimacy and sexuality, it
should also be acknowledged that any coercive or unsafe behaviours are unacceptable. Measures
need to be taken to ensure the protection of any resident who is deemed vulnerable on this
basis. Similarly, cases of hyper-sexuality should also be addressed immediately for the sake of
all concerned. For example, public masturbation is unacceptable because it can affront other
residents’ sense of dignity; therefore, any resident wishing to engage in this activity should be
directed to their own room (if private) or to a room designated for private purposes. The aged
care team needs to acknowledge that even behaviour that is unacceptable is driven by some
unmet need. The challenge is to seek to understand the message in order to help the resident to
fulfil this need in acceptable ways.
Although companionship and intimacy between two residents may appear benign at first
glance, these relationships may be objectionable to their spouses or adult children [337] (Level
QE). Researchers found that residents and spouses were less tolerant than staff of residents
masturbating, engaging in sexual relationships, viewing sexual materials, and making sexual
approaches to staff. [337] Privacy was the primary determinant of appropriateness for behaviours
for all groups. Staff and spouses were more likely than residents to endorse counselling for
behaviours perceived as inappropriate.
It would appear that any form of intimacy between residents may be problematic. [341] A simple
problem-solving framework offers a process for addressing these types of concerns:
1. Describe and document the behaviour in objective terms. Then ask “Is this really a
problem and, if so, for whom?” If it is a problem that exists for a resident, the aged care
team, family members or the facility then further assessment is required to identify the
triggers of the problem or the real issue; and
2. Develop a plan of care to be implemented and evaluate it to determine its effectiveness.
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