Guidelines for a Palliative Approach in Residential Aged Care

therapy, blood glucose monitoring, PEG/nasogastric feeding, and unnecessary medications.
There is no single description of an individual’s last hours of life, and the aged care team needs
to be alert to individual differences and the resident’s reactions to their impending death. The
family may also require more support at this time and the aged care team needs to be able to
provide this. The aged care team is in a unique position to assist families in coping with the loss
of a relative during the dying process and after death has occurred [373] (Level QE). This support
may need to be practical as well as emotional [399] (Level QE). (See Chapters 8 ‘Family support’,
and 15, ‘Bereavement support’, for further information).
The following story highlights some of the responses residents and their families may have when
facing imminent death.
Vignette 17: Ann and Mr Wells’ family
Ann, the nurse in charge, was aware that Mr Well’s death was imminent and she phoned
the family accordingly. Knowing the family, through her many discussions with them
over the previous year, she was aware of the difference of opinion between some family
members regarding the palliative approach to care and she knew that one daughter was
concerned about the recent introduction of opioids. Ann’s colleague thought it was “too
late” to call a family meeting: “Anyway, it’s not our business to get involved in their family
dispute!” Ann knew otherwise and gave the family this option: “You realise your father’s
condition is deteriorating, and as I’ve explained before, we can never predict precisely
when death will occur. I’m aware some of you are uncomfortable with the morphine
infusion, so I wonder if you’d like to meet with the doctor and myself about 2.30p.m. It’s
important that the whole team, which includes the family, agrees with the plan of care. It’s
also important, particularly at this stage, to ask ourselves again, what is in your father’s
best interests? This meeting will give you the opportunity to openly discuss any questions
and concerns.”
14.3 MEDICATION ISSUES
Practical comfort measures are very important in managing end-of-life symptoms, and are
often more effective than other interventions. Medical intervention is, however, frequently
required for specific symptoms. Several medications are recommended in the next section, but
for specific information such as dose levels relevant resources such as the Therapeutic Guidelines:
Palliative Care [109] or the Australian Medicine Handbook Drug Companion Aged Care [147] should
be consulted.
RACFs, in consultation with GPs and local pharmacies, should develop strategies to ensure that
residents who are approaching death have ready access to common terminal phase medications.
It is best to have the relevant medication orders and prescriptions ready for possible symptoms
in the end-of-life phase. [109] For example, restlessness, delirium and excessive respiratory
secretions are common symptoms that can develop quickly, so relevant medications should be
readily available, with sufficient ranges of dose to deal with a worsening of symptoms; these
should be ordered by the GP.
When the resident is approaching death, the use of oral medications should be reviewed. Some
medications, such as hypoglycaemics, anticoagulants and antihypertensives, may no longer
164 Guidelines for a Palliative Approach in Residential Aged Care