Many residential aged care facilities have structured approaches to support care of residents dying in the facilities. Nurses should check what policies and procedures are available in their facility.
Residential Aged Care End-of-Life Care Pathway (RAC EoLCP)
A terminal care management document is designed to help make consensus-based best practice palliative care possible for older people in the terminal phase of life (ie, they are actively dying).
It is intended to support residential aged care facility staff in their efforts to ensure that the older person who is dying will do so with the best available care in place.
Many facilities have adopted at the Residential Aged Care End-of-Life Care Plan Pathway (RACEoLCP) as the terminal care document. The RAC EoLCP is a clinical tool that:
- Provides a guide for delivery of evidence-based, best practice palliative care.
- Provides a template to record evidence of care as it is delivered.
- Ensures good quality, standardised care for all older persons.
- Supports quality assurance and audit processes.
The PA Toolkit RAC EoLCP has been shown to reduce the proportion of residents transferred to hospital for terminal care.
- Commencing a resident on the RAC EoLCP
It is usually appropriate to start the pathway if three or more of the following symptoms / signs are displayed by the resident:
- Experiencing day to day deterioration that is not reversible.
- Requiring more frequent interventions.
- Unable to take oral medications.
- Becoming semi-conscious, with lapses into unconsciousness.
- Increasing loss of ability to swallow.
- Refusing or unable to take food or fluids.
- Irreversible weight loss.
- An acute event has occurred, requiring revision of treatment goals.
- Profound weakness.
- Changes in breathing patterns.
The final decision to commence the RAC EoLCP is a clinical one, supported by the views of the multidisciplinary team and/or the older person and their substitute decision-maker or person responsible, as appropriate.
- Communication with Resident or Resident’s Representative
When delivering the news to family that the older person is dying, begin by:
- Identifying the resident’s nominated representative and inform them that the older person is dying.
- Confirm the nominated representative’s contact details and availability.
- Provide an opportunity for the nominated representative to express any concerns and document and address key issues.
- Broach grief and loss issues with the older person's nominated representative.
- Use the Bereavement Risk index to identify people at potential risk following the death of the resident.
- Medical interventions and ACP
To begin the RAC EoLCP a medical review of essential medications and documents about advance care planning should be conducted.
The medical review should be completed and signed by either the general practitioner or palliative care medical officer within 48 hours of gaining verbal authorisation to commence the pathway. Nurses can support GPs in this review by asking if all medications are still needed and by highlighting the need for PRN medications to care for the resident.
Once consent to start planned management of the terminal phase has been received, the following activities will be undertaken:
Review of Medical Interventions
- Review all existing medications and cease all non-essential medications.
If oral administration of medications is no longer possible and/or appropriate then highlight need for medications by an alternative route (eg, subcutaneous).
- Cease non-essential clinical interventions and observations (eg, blood pressure monitoring, blood sugar levels).
- Order as-needed (PRN) medications for anticipated symptoms.
Advance Care Planning
The residential aged care nurse should:
- Inform the older person (where possible) and their representative of the decision to commence the pathway.
- Discuss future care, including wishes regarding transfer to hospital and the appropriateness of ceasing other life-sustaining measures.
- Discuss and agree upon a ‘not for resuscitation’ (NFR) order with the older person and/or their family / substitute decision maker.
Goals of Care
- Provisions to allow for natural death.
Care Practices
- Support cultural, spiritual and religious practices.
- Ongoing communication with the resident and the resident’s family.
- Enable ongoing comfort of the resident.
The comfort care chart lists a set of comfort-focused observations that are reviewed four hourly at a minimum.
- The frequency of observation is determined by individual residential aged care facilities.
Use of a Comfort Care Chart
Many facilities use a comfort care chart system to document the frequency of observations, the nature and changes in symptoms and care responses.
Find out more
- Multidisciplinary Communication Sheet
Communication is important to have continuity of care. Some facilities use a chart is for members of the multidisciplinary team to record any communication or treatment notes while the older person is dying.
The PA Toolkit has an example (37kb pdf).
Using the facility’s current paper- or electronic-based progress notes is also an alternative but should be in an accessible format for all of those who may need to enter information into it.
Following the death of the older person, the registered nurse completes this section of the chart.
This section of the chart provides a checklist of tasks that need to be completed and ensures that all the relevant people are informed of the death.
It is important that the presence of any ACP or ACD has been documented by the RACF and by the GP is transferred if appropriate. Systems should be in place to ensure this information transfers with the patient, should they require care in another facility. In addition, the SDM should hold a copy of the ACD in order to be able to provide it if required.
In considering a transfer to hospital, it is important to attend to the resident’s stated preferences and wishes. Specific refusals of medical treatments and interventions should be respected if they are intended to apply to the current circumstances. The benefits and burdens of any transfer should be weighed.
The
Decision Assist Advisory Telephone Service can provide advice on palliative care symptom assessment and management and on care management decisions.
Most facilities have procedures for after death care. After a resident’s death, facility staff may clean the body and tidy the room so the family can spend time with their loved one.
The funeral company will be responsible for the body after death certification.
Make arrangements to sort out the resident’s belongings and to release the room in a respectful way that acknowledges the family’s loss.
Staff can assist by packing items and organising an appropriate time to collect the resident’s clothes, pictures, personal belongings, books and other items.
Remember for many family members, the resident’s room has been the home of their family member. The family should be advised on any other facility responsibilities such as release of bond or return of furniture or equipment.
Remember the family will feel the loss of their loved one. Some family members may need support in their bereavement.
Carers Australia has information that may assist family members or carers during their bereavement period.
Death audits are part of continuous improvement and quality control in implementing a palliative approach in residential aged care.
The benefits of death audits:
- Facilitation of evaluation and performance review.
- Assessment of achievement of goals.
- Informing decision making about next steps.
Two audit tools have been provided to help start the process:
Brisbane South Palliative Care Collaborative. (2013).
Workplace Implementation Guide: Support for Managers, Link Nurses and Palliative Approach Working Parties (635kb PDF). Brisbane: State of Queensland (Queensland Health)