more_vert
AT the Royal Commission into Aged Care Quality and Safety last Thursday, Professor Joseph Ibrahim laid it on the line.
“[Aged care residents] know they’re going to die. We know they’re going to die,” he told the Commission. “What currently happens is most of us sit around waiting for them to die, and if they die quickly, then it’s a good job done. Everyone thinks that’s a good thing, and it’s clearly not.”
Senior Australians living in residential aged care facilities (RACFs) were “stateless”, he said.
“The parliament does not care about people in residential aged care. If they truly care they would do something or at least say something. They don’t say anything. They don’t act.”
Professor Ibrahim, the Head of the Health, Ageing and Law Research Unit at the Department of Forensic Medicine at Monash University, has written a Perspective published in the MJA, and has spoken exclusively to InSight+ in a podcast.
Just like in his Commission appearance, he pulls no punches.
“In residential care, if you die before your time, most people think that is a positive outcome because you have relieved suffering,” he says in the podcast.
Family might say that their elderly relative – who may have had dementia or severe arthritis – was now in a “better place”, and aged care staff and medical practitioners may view the death as expected.
However, he said, no one should die from the actions or inactions of others.
In his MJA article, Professor Ibrahim argues that health care has been “uncoupled” from aged care. He called on the Royal Commission to take a “transformative approach that included tightly coupling” RACFs to health care.
“RACF business models are moving away from a perceived medically dominated model of care provision. This trend does not serve the rights of older people in residential care to equitable access to health care,” Professor Ibrahim wrote.
In the podcast he said he was not asking for people to have an eternal life.
“Prompt diagnosis, prompt follow-up, responding to abnormal tests, communicating between professionals, that is all we are asking for, which is the standard that’s expected in health care generally.
“If we attend to those details, then there would be substantive improvement in the quality of life for the [aged care] residents.”
He said optimal health care was essential in improving the lives of older people and this should be one of the core roles of RACFs. He called for the medical profession to establish new standards, use performance data and to advocate for structural solutions that support the use of evidence-based care.
Professor Ruth Hubbard, Professor of Geriatric Medicine at the University of Queensland and consultant geriatrician at Brisbane’s Princess Alexandra Hospital, said there was a general attitude in the acute sector that acute hospitals were not the right place for frail older people, particularly those residing in nursing homes.
“That sometimes isn’t true,” Professor Hubbard told InSight+. “When there is an acute problem that would benefit from a thorough medical assessment, physicians in the acute sector are expecting more and more of general practice, for example, in the management of these very complex, very frail older people in [RACFs].”
Professor Hubbard said more sophisticated health care models were needed to address the complex needs of aged care residents.
“These are people who are usually in the last year or two of their lives,” she said. “If they were identified as having cancer, for example, then the medical workforce would be mobilised to address their symptoms, but because a lot of [aged care residents] are identified as having dementia, we don’t quite have the same systems of support for that clinical diagnosis.”
Professor Gideon Caplan, Director of Post-Acute Care Services and Geriatric Medicine and Conjoint Associate Professor, UNSW, The Prince of Wales Hospital, said the Royal Commission provided a timely examination of an area in great need of review.
“People who work in RACFs on the whole do an amazing job with limited resources in difficult circumstances,” he said, noting that his comments related to high care in RACFs.
“They care for frail older people with multiple comorbidities, very high rates of dementia and behavioural and psychological symptoms of dementia which are often very difficult to manage but need a great deal of care. The residents are at the end of their lives and are entitled to be treated with dignity and respect.”
Professor Caplan said better systems to ensure quality of care were needed and he supported the call for general use of quality indicators, which would help facilities to improve their care by benchmarking.
However, he added, this must be done carefully.
“The end result of nursing home care for permanent residents is almost universally death, so we have to understand that the natural trajectory of a permanent stay in a nursing home is declining health towards death. Nursing homes are essentially palliative care facilities for people with dementia,” he said.
Professor Caplan said he “strongly disagreed” with Professor Ibrahim’s statement in his MJA article that the provision of outreach interventions and care from acute hospitals was “evidence of a failure to recognise and align practice to the contemporary needs of the RACF population”.
“These services are almost universally geriatrician-led, and the author later says the Royal Commission should ‘investigate the absence of routine roles for geriatricians’ and ‘tightly coupling RACFs to health care’. These services bring a routine geriatrician input into nursing home care,” said Professor Caplan, adding that he had been managing geriatrician-Ied services from hospitals into nursing homes for 25 years.
Professor Caplan said research that he had conducted had shown that nursing home residents do better by avoiding in-hospital treatment, with a 10% reduction in mortality.
Professor Hubbard agreed that outreach services could provide a key role in aged care delivery, but their availability throughout Australia was “patchy”.
“Sometimes it is better for older people to remain in their own environment. Whether that be a nursing home or in their own home, but there shouldn’t be blanket rules about that, it should be individualised,” said Professor Hubbard.
“At the moment, there is a pressure on some older people who are being discharged into a nursing home to formulate an advanced care plan that includes the decision not to come back to hospital. This is ridiculous – if you fall and break your hip then you need to have an operation and you need to come back.”
Professor Hubbard said innovative solutions, such as telehealth services, were needed to improve health care in nursing homes.
Associate Professor Glenn Arendts of the Centre for Clinical Research in Emergency Medicine at the Harry Perkins Institute for Medical Research said it was widely acknowledged that the current model for providing medical care in aged care was “broken”.
“I don’t think anyone would argue that we are optimally managing medical conditions in aged care,” said Associate Professor Arendts, who specialises in acute geriatric care in EDs. “The problem is we don’t really know what the ideal model should be.”
He said it was important to avoid the “over-medicalisation” of the aged care sector.
“There are 2500 aged care facilities in Australia, and the last thing we want is 2500 mini-hospitals, with a very medicalised model of care.”
Associate Professor Arendts felt that improved data collection could help to drive improvements in medical care provision in aged care.
“The Australian Commission on Safety and Quality in Health Care publishes an Atlas on Health Care Variation for all sorts of medical procedures, but we don’t have that same atlas of variation for outcomes in residential aged care,” he said, adding that he hoped the Royal Commission would recommend improved data-driven understanding of variation in aged care practice.
He said variation data could positively, rather than negatively, influence practice.
“Sometimes people feel these data are going to be used in a punitive way, but I can see them being used in a very positive way to highlight areas where people are doing things well, so we can all learn from them.”
Loading ...
My father went into a home and only lasted a week thanks to the home not giving him his blood thinners and heart medication.
I agree with Professor Ibrahim.
I believe these older people need to be loved and cared for and given the same good treatment as though they were young and starting their lives. They should live with dignity.
The aged care system should be restructured from the bottom up.
We must always remember that one day we will require an aged facility. What do we want for ourselves. There should be two doctors per home and more than one nurse per 120. There should be 1 nurse per 10 at least.
My family were severely failed by aged care and are still grieving.
Ted Collinson had it right. A permanent doctor (or 2) for each nursing home. The patients get continuity of care, dementia patients feel safe because they know the doctor, and pitfalls in the system get recognised. The other useful change would be for GPs to authorise IV antibiotics to be given by hospital in the home staff and access to hospital x-ray facilities without having to burden A&E.
Having worked in both general practice and palliative care , my observations would be :
GPS need to be properly reimbursed for visits . Aged care residents have multiple and complex medical issues . These take TIME to properly address . Families also need to be given time for communication of issues concerning their relatives .
The skill in caring for these vulnerable frail patients is in knowing when to treat and transfer and when it is more appropriate for end of life care in situ. After 35 years ( now retired) in medicine, it seems the obvious solutions are often ignored :
GPS should have access to geriatricians ( or a nurse practitioner ) , palliative care service for consult and advice , with prompt response times .
Reward GPS with extra qualifications in aged and palliative care with higher remuneration. You need a TEAM for aged care : Physio, OT, nurses and of course the much under appreciated carers. So much could be done for residents’ comfort and dignity with a dedicated team .
But of course : back to the Federal/ State money divide ! Easy option : send to an acute hospital ,
Bounce the patient back out and very little is achieved .
Time to rethink the model and ensure that the rethink includes not just aged care hospital
Specialists but GP s, palliative care
Docs , psychogeriatricians,nurses and others like OTs and Physio.
We need a new wheel not just a re tread .
Aging is a life process .Just like birth,growing & death.. None of these are medical issues and as such the medical model led by doctoes does not work well as a basis for designing both the physical and emotional worlds for older Australians.On the whole the medical profession does not cope well with dying and tends to obsessively try to aviod it happening . They talk about tests ,diagnosis and treatments ..But if life is more than a diagnosis for someone who is 30 then it should be more than that for someone who is 80.
What we have in Australia right now is a neo-liberal inspired war between corporates /NGOs on one side who see older Australians as consumers in a business model which proiritises monatary efficiences & the medical professional.on the other which sees Older Australians as consumers of their medical care .Neither sees them as whole people with talents, opinions, likes ,dislikes ,hope ,dreams,memories rights..People really.
“What you are I once was .What I am you one day will become”(saw this on the wall.of a crypt in a Roman Church)
A/Prof Glenn Arendts may not know what the ideal model of aged care should be, but considers it important that “over-medicalisation” of aged care should be avoided. Over-medicalisation is not a risk. At present people in receipt of residential aged care are discriminated against, and do not have the same access to care as the rest of the Australian population. In the 1980s and 90s in SA, at least in Adelaide, the Regional Domiciliary Care and Rehabilitation Services provided aged care services that included hospital care, home care and home-based rehabilitation, dementia support, collaboration with all the health and welfare agencies in our regions. We introduced, housed and staffed the Aged Care Assessment Teams. We had an opposition made up of some of the prominent NGOs, who considered assessment and rehabilitation to be Medical Model in its pejorative sense, and promoted Normalisation, a distortion of a methodology developed in Scandinavia for dealing with developmental disability in childhood by an American prophet called Wolfsenburger. They got their wish. When the Commonwealth took over the funding we disappeared. These NGOs and A/Prof Arends do not seem to understand the significance of the word “care”. The money is intended to be spent on people who need care by virtue of disability as confirmed formal assessment.
Dear Ian Hargreaves … what a ridiculous comment. As if the vast majority of Australian seniors can afford $300,000 a year in personal carers. By the way, 24/7 care in the home is closer to $370,000 per year, speaking from experience. If you really believe the residential aged care system is okay, and if you don’t like it, find $300k a year, then you are living on a cruel dream planet which bears no resemblance to reality
Reading the MJA paper was like reading the Pope’s thoughts on contraception, or Bill Shorten’s advice to employers. It would be more credible had the author actually currently run a nursing home, and demonstrated that he had a better success rate than average.
Aged care suffers from the same issues that the bedevil all medical practice, demand is limitless and cash is finite. It is easy for armchair experts to quote studies that weaning off psychotropics is a good thing, while simultaneously criticising as egregious criminality when a resident assaults another resident. When working as an AIN in a nursing home I had a confused resident try to stab me, and witnessed my colleague being bitten by a resident. It is very hard to protect staff and other residents against confused/demented residents.
I suspect most endocrinologists would tell you that managing diabetes when the patient has no capability of self-medicating/self-monitoring is difficult, so the figure of 10% hypo- and 69% hyperglycaemia is not the same significance as it is in a healthy adult population. It sounds like aiming for a middle path, and erring on the high rather the low side.
While it is nice to say that people “are entitled to be treated with dignity and respect”, the staff member who is dealing with the confused, dangerous resident without the use of physical or chemical restraints is not available to monitor the blood sugar of the resident sitting in the corner. Are they eating an entire box of chocolates their relatives kindly brought them, or not eating anything since their insulin?
Your aged relative can get one-on-one devoted, competent attention in their own home for only about $300,000 per year, assuming you have no additional Workcover fines, excessive sick leave/unexpected maternity leave etc. Or you can care for them yourself in your home, and if you can devote as little as 1/10th or more of your time to your relative, they are far better off than in a commercial facility.
Or if you really care, open your own nursing home to care for the most demanding and difficult residents for a fair and reasonable fee, in a peaceful garden setting with unobtrusive security features, providing a stimulating range of activities tailored to each resident’s needs, paying your staff over award wages with exemplary working conditions and high staff/resident ratios, providing varied cuisine with nourishing meals, paying your local GPs a decent hourly rate to have them staff an on-call roster 24/7, and making sure you comply with (or preferably exceed) all local, state and federal regulations. I’ll put my name on your waiting list.
I have debriefed carers in the course of my employment, some of whom work in Aged Care Facilities. Some of these have been traumatised by what they describe as the appalling treatment some Aged Care Inmates have received. Some of these are clearly the victims of Elder Abuse. Most of the aged clients I work with dread going into an Aged Care Facility, and, I think, with good reason. Some are choosing to die prematurely to avoid a Residential Home.
There also seems to be a disturbing undercurrent – a feeling that, yes, this or that old person has cancer, but who cares, they are lucky to have survived this long, and the medical resources available should be directed towards younger people.
Perhaps we need an Old Persons’ Union? Or, more realistically, some sort of regular and consistent oversight, with regular and un-announced inspections.
I specialise in aged care in my practice and look after most of the residents in two RACFs. As the main visiting GP I am in a good position to detect failures in care and I will discuss these with the management and work out solutions. Where an RACF has a number of visiting GPs with no single main GP it is difficult for any failures to be corrected as no GP has much of a vested interest in the RACF. I would like to see RACFs funded to have a main visiting GP who is involved in maintaining / improving the standards of clinical care in the facility.
The lack of funding is hamstringing many facilities and is a sad indictment of our political system.
There is no almost about it. The end of all human lives is universally death. This reality should not cloud the issue of caring for the living. We must extend adequate levels of care to all human beings at every stage of their lives, and perhaps even more so for the aged and frail who have also, as have those less fortunate amongst other generations, lost their independence. As with the disabled, we need a positive outreach to the frail and elderly.
Nearness to death is NOT an excuse for substandard care. It is a cry for adequate, timely and compassionate care.
The aged care industry is transitioning with the help of government to a large extent to be run by corporates whose over riding dogma is compliance with bureaucratic legislation rather than the delivery of care. Don’t get me wrong i understand their need to avoid litigation but they dispatch residents to nearest hospital without medical input or approval. This costs the health system of the order of $5,800 odd dollars for each referral when one considers 2 ambos, an ambulance ,a triage nurse, resident medical officers time ,investigations plus or minus hospitalisation and the return of the resident etc. Aged care facilities need to be that care facilities and medical practitioners need to deliver that care not be rubber stamps to the nursing homes protocols.
End of life documentation needs to be part of all wills and not left to compromising situations or 2 weeks before ones death. Decisions need to be made by the person when they are competent and truly be an expression of what they want and in accordance with their wishes. No wills after 75 should be valid given over 45% of the population at age 90 has dementia.
It is time for the law society to step up to the mark and institute the above necessities of life and protect our senior citizens honoring their contribution to the Australian society.
We need to have a wholesale review of aged care facilities that includes hiring competent compassionate staff and paying them properly dd
Dodgy nursing homes have always been among us. Forty years ago, the worst were well known. Now, it’s harder because psychopathic, uncaring behaviour hides behind diplomas, snazzy architecture and fresh paint. However, the residents’ families and the doctors know who they are. Just ask them.
I have been retired from a medical career for 12 years. I recently sold my house and moved into a Ryman retirement village which will ultimately have 325 independent living apartments and 100 special assisted care one bedroom apartments. There are emergency alarms and never alone alarms in all apartments. There is excellent nursing care and carers on hand 24/7. A doctor is also on call 24 hours a day and the style of living could not be better. Social functions and activities are arranged every day. Organised exercise is arranged for those who wish to participate and although the apartments are not owned, they are purchased on a long term lease…hardly homeless!
I wonder if Prof. Ibrahim has visited some of the better run retirement villages and if he hasn’t then a lot of what he has written is bunkum.
Thank God for Professor Ibrahim. The rest do not understand the issues. I can verify this having had to cope with my own mother, a retired GP, through the extended emotional trauma of substandard home care, multiple aged care assessments that were not across all the issues, refusal of basic services such as rehab for back pain, collusion between hospital teams to force outcomes to get rid of troublesome geriatric patients, blatant attempts at manipulation of the “family” by young residents and social workers and finally placements in low care facilities that were lacking in basic human decency as well as being staffed by carers who were undertrained and underpaid. And then me trying to keep working and look after a school aged child while being down the rabbit hole in the bizarre alternate universe that is aged care in this country.
For Professor Caplan to say that “The end result of nursing home care for permanent residents is almost universally death…” is a way of excusing a system from providing compassionate health care and personal care related to their needs that everybody in the community is entitled to, particularly those that have worked all their life, payed their taxes for many years. They expect the same level of health care that everybody else in the community receives, but do not receive it when they actually need it.
We need data about the proportion of aged care facilities that have access to geriatrician-led outreach services. All older persons in aged care in Australia deserve to have their medical needs responded to with skill and compassion – not just a lucky subset.