Guidelines for a Palliative Approach in Residential Aged Care

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in the RACF rather than transferring them to an acute setting. [6,47] These decisions are usually based on the resident’s familiarity with the aged care team and the facility, adequate care already being provided in the RACF, a request from the resident, their family or the GP, or a lack of hospice beds. [6,47] A palliative approach can usually be provided in an RACF. [6] This offers benefits to the resident and family through consistency and continuity of care. In some instances there may be a need for intermittent specialised palliative support when residents have complex symptoms or the aged care team requires additional support. However, this consultation can often occur while the resident remains in the RACF. Guideline: Where can a palliative approach be provided? Ref No. Evidence level 3. A palliative approach can be provided in the resident’s familiar surrounding if adequately skilled care is available, which reduces the need for transfer to an acute care setting; thereby, avoiding potential distress to the resident and his/her family. 6, 23 QE 2.4 WHO CAN PROVIDE A PALLIATIVE APPROACH? A palliative approach is best provided by an effective multidisciplinary team [48,49] (Level QE) [50] (Level III-2). An effective team recognises and acknowledges that team members are likely to have different perspectives about a palliative approach, yet team members are able to clarify and address the reasons for these differences. When a multidisciplinary team uses this approach, their job satisfaction improves as does the quality of care that is provided to residents and their families [48] . A team approach to care planning also facilitates the aged care team in providing residents with highly individualised care, which allows for the discussion of advance care plans that address prognosis, emotional preparation , and appropriate use of medical treatments (including the potential benefits and disadvantages of treatment decisions) [49] (Level QE). 2.4.1 What is a ‘multidisciplinary team’? A multidisciplinary team is a group consisting of three or more people from different disciplines who collaborate in making decisions about all aspects of diagnosis, treatment and care of residents and their families [48,49] (Level QE). Effective multidisciplinary teams can provide support and symptom control to improve the quality of both living and dying for residents and their families through a palliative approach. This multidisciplinary approach is critical to the success of a palliative approach because the wide variety of forms of distress experienced by residents and their families requires a broad range of skills [49] (Level QE). The multidisciplinary team focuses its efforts on addressing the problems that are of most concern to the resident [49] (Level QE). Barriers to appropriate treatment, such as confusion over pain medications, whether a facility has access to requisite medications, and uncertainty about the benefits of treatment, can also be addressed. Guidelines for a Palliative Approach in Residential Aged Care 43
2.4.2 Who are potential members of a multidisciplinary team? Potential members of a multidisciplinary palliative team [51] (Level EO) might include, but are not limited to: • Care assistants; • General practitioners (GPs); • Generalist nurses (i.e. Registered Nurses (RN), Enrolled Nurses (EN)); • Specialist nurses (e.g. continence, wound care, palliative care, nurse practitioners); • Aboriginal health workers; • Volunteers and coordinators of volunteers; • Pharmacists; • Chaplains/pastoral care workers; • Recreational activities officers (these aged care team members are commonly used in RACFs and have considerable direct contact with residents); • Pain specialists; • Allied health practitioners (e.g. occupational therapists, physiotherapists, speech pathologists, • social workers, diversional therapists, dieticians, music therapists and podiatrists); • Specialist physicians (e.g. surgeons, neurologists, geriatricians, oncologists, wound care specialists and radiotherapists); • Community palliative services; and • Psychologists/psychiatrists. The resident and their family, as well as being recipients of care, if willing, are also essential members of the palliative team. 2.4.3 How should a multidisciplinary team function? One member of the team usually assumes the role of coordinator (e.g. the Director of Nursing, or other suitably qualified nurse, or the GP) [52] (Level QE). Depending on their roles, different members of the team have varying perceptions of a palliative approach, necessitating cooperation and good communication among members [48] (Level QE). Effective communication and teamwork are considered by nurses and GPs working in RACFs to be essential aspects of a palliative approach [31] (Level QE). Effective multidisciplinary teams are able to articulate common goals and work in a collaborative, non-hierarchical environment. [53] They meet regularly to assess and discuss progress and are able to devise protocols for providing a palliative approach. [49,54] 2.4.4 Staffing skill mix There is no sound evidence on the minimum number of representatives from each discipline (nursing, social work, pastoral care, etc) needed to develop a palliative approach. RACF managers should determine the skill mix and allocated hours of the aged care team, taking into consideration the level of dependency of residents, the complexity of needs, and the availability of external palliative care services. Given that a palliative approach, rather than specialised 44 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
Page 5 and 6: 4 ADVANCE CARE PLANNING 55 4.1 Impl
Page 7 and 8: 16 MANAGEMENT’S ROLE IN IMPLEMENT
Page 9 and 10: 17 Ann and Mr Wells’ family Helpi
Page 12: IMPORTANT NOTICE On 8 December 2005
Page 15 and 16: achieved for these guidelines from
Page 17 and 18: facets of a palliative approach are
Page 19 and 20: Additional levels of evidence The N
Page 21 and 22: Guidelines Ref No. Evidence level A
Page 23 and 24: Guidelines Ref No. Evidence Cachexi
Page 25 and 26: Guidelines Ref No. Evidence Anxiety
Page 27 and 28: Guidelines Ref No. Evidence 70. Und
Page 29 and 30: 1.1.1 Aims The aims of the systemat
Page 31 and 32: Table 1: Search terms Terms Aborigi
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Page 35 and 36: in the methodology that may invalid
Page 37 and 38: To ensure the reliability of the re
Page 39 and 40: 1.2.2 Methodology When the first re
Page 41 and 42: 1.4.2 Method When feedback was requ
Page 43 and 44: Several Working Party members conve
Page 45 and 46: or disagreed with each stakeholder
Page 47 and 48: All the feedback received was colla
Page 50 and 51: CHAPTER 2 A PALLIATIVE APPROACH A s
Page 52 and 53: • Profound weakness • Trouble s
Page 54 and 55: • Has the resident had a recent d
Page 58: palliative care teams is more appro
Page 61 and 62: or ageing progression (see Table 4)
Page 63 and 64: Table 7: A practical model of socia
Page 65 and 66: Vignette 2: Robert’s story Robert
Page 68 and 69: CHAPTER 4 ADVANCE CARE PLANNING Car
Page 70 and 71: efore discussing the advance care p
Page 72 and 73: • A change in their health status
Page 74 and 75: CHAPTER 5 ADVANCED DEMENTIA Advance
Page 76 and 77: A study was conducted to investigat
Page 78 and 79: 5.3.2 Acute illness One study found
Page 80: Vignette 5: Anna’s story Anna was
Page 83 and 84: (see Fainsinger, Miller and Bruera
Page 85 and 86: Dame Cicely Saunders first describe
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
Page 93 and 94: Vignette 7: Mrs Harris’ story Mrs
Page 95 and 96: examined the addition of paracetamo
Page 97 and 98: provision and storage of drugs, whe
Page 99 and 100: successfully tested predominantly w
Page 101 and 102: The reasons for malnutrition in old
Page 103 and 104: The diets of residents should also
Page 105 and 106: To assist in such a discussion, a d
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appear until dehydration is far adv
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Guideline: Hydration 24. Recommenda
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6.7 NAUSEA AND VOMITING Nausea is t
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• Do you have any problem control
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6.9.1 Assessment A thorough oral as
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6.10 SKIN INTEGRITY The major skin
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Wounds can occur in residents for a
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Brocklehurst and colleagues (1999)
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medication treatment along with non
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• CAM therapies may be culturally
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word games, the present day, and fa
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CHAPTER 7 PSYCHOLOGICAL SUPPORT A r
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7.1.1 Death statements and depressi
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the factor structure of the CSDD. I
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7.2.2 Management Non-pharmacologica
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Table 17: Distinguishing delirium f
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is recognised that in many rural an
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important [305] (Level QE). Familie
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8.4 FAMILY INVOLVEMENT The role of
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CHAPTER 9 SOCIAL SUPPORT, INTIMACY
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Rather than denying the existence o
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9.2.2 Management Imaginative progra
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Guideline: Social Support Social Su
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include lack of information about t
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CHAPTER 11 CULTURAL ISSUES Australi
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11.2 Assessment The best approach t
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CHAPTER 12 SPIRITUAL SUPPORT Dein a
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Vignette 13: Jack’s story Jack wa
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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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