Guidelines for a Palliative Approach in Residential Aged Care

e relevant, and may even worsen symptoms if continued [146] (Level EO). However, such
decisions should be made through negotiations between the resident and/or the family and
the doctor. The Guidelines for Medication Management in Residential Aged Care Facilities [400]
should be consulted when making any decisions about medication management; although
these guidelines are neither evidence-based nor specific to palliative care they provide sufficient
guidance regarding medication management in general in RACFs.
Oral administration of medications is not feasible if there are swallowing difficulties, nausea,
intestinal obstruction and decreased level of consciousness. Some medications are amenable
to being crushed for ease of swallowing; however, many result in adverse effects. Therefore,
it is recommended that the Guidelines for Medication Management in Residential Aged Care
Facilities [400] is first referred to because it contains a list of medications and their effects
when crushed altered. For example, when Oxycodone (Oxycontin) is crushed its absorption
characteristics become altered.
[400, p. 51]
Alternatively, some medications may be administered in transdermal, sublingual or rectal routes;
however, in most circumstances subcutaneous administration will be required for effective symptom
management. The subcu taneous route is preferred to other parenteral routes (intramuscular,
intravenous and epidural) because it is less invasive and has fewer risks of infection.
Syringe drivers (e.g. the Graseby Pump) are commonly used for a palliative approach in the
home-care setting to administer subcutaneous medications when death is imminent and other
routes of administration (e.g. oral) are not appropriate. However, their use should be governed
by the need for 24-hour administration of a medication and/or staff resource considerations.
Common issues regarding the use of syringe drivers, including practical advice and drug
compatibilities, are discussed in the Therapeutic Guidelines: Palliative Care. [109] RACFs need
to develop strategies to facilitate ready access to a syringe driver (should one be required) and
information on relevant medications. If more than one syringe driver is being used in a facility,
they should be of the same make and model to reduce the risk of error.
Where appropriate, members of the aged care team (including GPs) should be selected for
training in the setting up and maintenance of syringe drivers. Local community palliative
services and the syringe driver manufacturers should also be contacted where necessary to assist
in developing syringe driver strategies and protocols.
14.4 MANAGEMENT OF END-OF-LIFE CARE
Although most end-of-life care can be provided in the RACF, if a resident’s symptoms remain
uncontrolled the aged care team should consult the nearest community palliative service. It is
also important to clarify the wishes of the resident and their family concerning hospitalisation.
Ideally, residents should remain in their familiar environment (i.e., the RACF), provided the
aged care team has access to the necessary resources for optimal symptom management. (See
Section 2.3, ‘Where can a palliative approach be provided?’ for further information on the
suitability of RACFs to provide a palliative approach).
14.4.1 Pain and discomfort
When death is imminent, the resident’s comfort is paramount. However, it is a myth that
uncontrollable pain frequently develops in the last hours of life when it has previously not been
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