Guidelines for a Palliative Approach in Residential Aged Care

Vignette 1: James’ story
James, an 89-year-old war veteran, came into the high care facility with one leg having
been amputated several years before. Now ischaemic heart disease and other medical
complications indicated his life expectancy was short. When the telltale signs of poor
circulation appeared in his other leg, a family meeting was called. “He couldn’t take
another operation”, was the opinion of one son. “Can’t you just keep him comfortable?”
It was very difficult to keep James comfortable, because the pain was severe. No one at
that stage had thought to ask James, who appeared to be increasingly miserable, refusing
to get out of bed. Family and the aged care team agreed that he had “no quality of life”.
As the pain increased the doctor presented James with the options. “We could operate but
it would mean another amputation”’ James said, “Well, I’d rather have that than the pain.
The pain is killing me!” James’ post-operative recovery was uneventful, he ventured into
his self-propelling wheel chair again, his sense of humour returned and he lived for several
more months.
If a resident makes a statement that reflects a desire for hastened death, then it is essential that
this remark is comprehensively explored by a suitably qualified member of the aged care team,
as illustrated by the stories of both James and Robert.
3.3 ‘DESIRE TO DIE’ STATEMENTS
Sometimes the aged care team caring for residents with an advanced disease or in the final
stages of the ageing process are confronted by statements indicating that the resident may wish
for a hastened death. Such statements may provoke concern and confusion for the aged care
team, who may be uncertain about how to respond. The team may find themselves grappling
to determine if the resident is depressed, suicidal or seeking help to hasten death; or they may
believe the expressed wish is an understandable response to the resident’s circumstances. [62]
Occasional thoughts of suicide are not uncommon in palliative settings [63] (Level IV). However,
sustained suicidal ideation is less common and all statements of this nature warrant care and
attention [64] (Level QE).
• The reasons for ‘desire to die’ statements may be associated with issues such as:
• feelings of hopelessness, depression, guilt, unrelieved suffering and a wish for selfpunishment
[65] (Level EO);
• a perception of being a burden to others, anxiety, existential distress and family issues [66]
(Level EO);
• a sense of loss of dignity and a perceived lack of control [67] (Level EO); and
• a sense of isolation, boredom and loneliness.
Any of these factors may lead to depression or contribute to a resident’s wish to hasten death.
Appropriate treatment may bring about a more hopeful outlook for the resident, even at the
end of their life [64] (Level QE).
Guidelines for a Palliative Approach in Residential Aged Care 51