Dying in residential aged care settings

health.qld.gov.au

Dying in residential aged care settings

Dying in Residential Aged Care Settings

Assoc. Professor Carol Grbich

Emeritus Prof Ian Maddocks

Deborah Parker

Professor Neil Piller

Margaret Brown

Eileen Willis

Penny Roe

FLINDERS UNIVERSITY

NHMRC Strategic Research 2002-3


Study Aims

1. Describe demographic and clinical profiles of

residents with non-cancer diagnoses in

residential aged care facilities.

2. Assess the palliative care needs of these

residents.

3. Examine the current contribution and demand

for palliative care services to aged care facilities.

4. Provide strategies to address unmet needs.

NHMRC Strategic Research 2002-3


• Stage one -Survey

Methodology

– Representative sample of facilities in South

Australia (response rate – 57%)

• Stage two – Prospective case studies

– 69 residents with a non-cancer diagnosis from

17 facilities tracked for ten-week period.

– Interviews with Directors of Care

NHMRC Strategic Research 2002-3


Stage One - Facility profile

• Sample represents 20% of SA beds

– Private not for profit – 50%

– Private for profit – 27%

– Government – 22%

• 57% metropolitan and 43% rural facilities

NHMRC Strategic Research 2002-3


Stage One - Palliative Care Policies

• 69% of facilities indicated a specific palliative

care policy

• 26% specific bereavement policy

• Analysis of policies provided indicated quality of

policies was variable

NHMRC Strategic Research 2002-3


Stage One - Palliative Care Contact

• 59% of facilities had consulted a palliative

care service for at least one resident

• Medium number of residents who received

a consultation was 3

• Facilities indicated satisfaction with clinical

and education support from palliative care

services

NHMRC Strategic Research 2002-3


Stage One - Current Palliative Residents

• 7% of current residents considered

palliative

– More high care than low care residents

identified

• 78% had non-cancer diagnoses

NHMRC Strategic Research 2002-3


Stage One - Staffing

• No current requirements for set skill mix

• Low care only facilities

– 75% no Registered Nurse on pm shift

– 88% no Registered Nurse on night shift

• Average residents cared for by RN

– High care (32 – 44 depending on shift)

– Low care (37 – 42 depending on shift)

NHMRC Strategic Research 2002-3


Stage One - Resident deaths

83%

17%

NHMRC Strategic Research 2002-3

Cancer

Non-Cancer


Stage One - Resident deaths away

100

80

60

40

20

0

89%

11%

89%

11%

36%

64%

High care Dual care Low care

NHMRC Strategic Research 2002-3

At facility

Aw ay


Stage One - Summary

• 83% of deaths that occur are non-cancer related

• 78% of residents currently requiring palliative care

have non-cancer diagnoses

• Death in an acute care setting is more likely in low

care only facilities due to decreased skill mix

• Palliative care policies including advance care

planning requires improvement

• Palliative care services see few residents

• 41% of facilities had no palliative care service

contact

NHMRC Strategic Research 2002-3


Stage Two - Methodology

• 69 residents from 17 facilities

• 10 week tracking period

• Case note review

• Consultations with the residents, staff and

family

NHMRC Strategic Research 2002-3


Stage two -Criteria

• Primary disease and/or other medical condition

indicates that treatment goals directed toward

palliative treatment intention

• Would you be surprised if the resident died within a

few months.

• At least one of the following:

• Multiple hospital admission over 6mths where goals are

palliative

• Documented trajectory of decline in functional status

• Recent impaired nutritional status

• Unanticipated medical crisis which has required end of life

issues to be discussed

NHMRC Strategic Research 2002-3


Stage Two – Resident Profile

• 61 residents classified high care

• Average age 84

• Average time in facility 3.2 years

• 72% Widowed, divorced or never married

NHMRC Strategic Research 2002-3


Stage Two – Resident Profile

• Karnofsky and Barthel index indicate highly

dependent for ADLs

13% artificial hydration and nutrition

60% uncooperative behaviour

68% disorientated

NHMRC Strategic Research 2002-3


Stage Two – Resident Classification

13%

46%

2%

3%

36%

NHMRC Strategic Research 2002-3

RCS 1

RCS 2

RCS 3

RCS 4

RCS 5


Stage Two - Diagnoses

Endocrine

Pulmonary

Neurological

Genito-urinary

Psychiatric

Musculo-skeletal

Dementia

Haem/ Cardio

23%

25%

26%

32%

36%

NHMRC Strategic Research 2002-3

61%

64%

80%

0 20 40 60 80 100


Anorexia

Anxiety

Restlessness

Weakness/fatigue

Dysphagia

Pain

Constipation

Stage Two - Symptoms

51%

51%

54%

55%

NHMRC Strategic Research 2002-3

57%

71%

75%

0 20 40 60 80 100


Stage Two – Mod/severe symptoms

Dysphagia

Oral discomfort

Constipation

Anorexia

Anxiety

Re stle ssness

Weakness/fatigue

30%

33%

34%

38%

42%

42%

49%

0 20 40 60 80 100

NHMRC Strategic Research 2002-3


Stage two - Symptoms

• Generally well managed

• 4 residents may have benefited from

palliative care review

• Issues for education

– Ordering of opioids

– Use of prn only pain medications

– Pain assessment

NHMRC Strategic Research 2002-3


Stage Two – Advance care planning

Living Will

Schedule 2

Medical Power of

Attorney

Enduring Power of

Guardianship

Good Palliative

Care Order

Pow er of Attorney

Enduring Power of

Attorney

3%

6%

7%

16%

16%

20%

NHMRC Strategic Research 2002-3

55%

0 20 40 60 80 100


Stage Two – Palliative Care Consults

• 3 residents known to palliative care service

– Complex family and pain management issues

– Provision of a volunteer and regular review

– Discussion of advance care planning

NHMRC Strategic Research 2002-3


Stage Two – Palliative Care Consults

• Directors of care

– Referral based on need not diagnosis

– Contact often informal (advice ) rather than

formal referral

– Those with dementia more likely to be referred

to Behavioural Unit not Palliative Care

– Referrals may be rejected depending on region

NHMRC Strategic Research 2002-3


Stage Two – Resident Deaths

• 16 of the 69 residents (23%) died

• 3 of these deaths occurred in a hospital

– 2 from low care and 1 from high care

– All had sudden acute episode of illness

• Deaths in the facilities were well managed

NHMRC Strategic Research 2002-3


Stage Two - Summary

• Dependent population with high percentage

of residents with cognitive impairment

• Palliative care consultation very low

• Symptom management raises education

issues

• No consistent approach to advance care

planning

NHMRC Strategic Research 2002-3


Recommendation One

• An increased liaison between palliative

care services and residential aged care

facilities.

– Designation of specialist team member to

residential care facilities

– Link nurse model

NHMRC Strategic Research 2002-3


• Education

Recommendation Two

– Minimum palliative care competencies for staff

– Financial assistance by the Commonwealth for

up skilling of staff

– Development of a learning package for General

Practitioners

NHMRC Strategic Research 2002-3


Recommendation Three

• Improved Commonwealth funding

arrangements to assist residential aged care

facilities’ capacity to meet residents’

terminal care needs is required.

NHMRC Strategic Research 2002-3


Recommendation Four

• Residential aged care facilities to develop a

comprehensive palliative care policy

– Definitions of the palliative care approach, palliative

interventions and specialist palliative care.

– Indicators of when to refer to specialist palliative care

services or implement palliative interventions.

– Reference where applicable to associated legislation

and standards

– A standardised simple and practical tool for advance

care planning

NHMRC Strategic Research 2002-3


d.parker@qut.edu.au

NHMRC Strategic Research 2002-3

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