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A RECENT sequence of letters to the MJA has been particularly relevant in the light of recent revelations from the Royal Commission into Aged Care Quality and Safety.
The issues highlighted include the so-called “triple jeopardy” for patients in residential aged care: advanced age, cognitive decline and mental illness. As highlighted in the exchange of letters (here, here and here), residents whose behaviour places them in the “too hard basket” for residential facilities can find themselves exported to emergency departments with a one-way ticket and a refusal to return after hospital discharge.
Quite apart from violating both contractual and civil rights, this phenomenon tells us a lot about the way risks are managed in the residential aged care world.
We have heard heartbreaking stories from the Royal Commission about patients being restrained in chairs, often soiled, and being sedated to the point of unresponsiveness. We have heard from aged care experts about alternatives to restraint, and also from facility staff about the acts of violence committed towards them and other residents.
Use of restraint – physical or chemical – should be the last resort in the management of difficult behaviour. Residential aged care facilities do not have enough skilled staff to maintain successful use of alternative behaviour management techniques (as well as the delivery of other essential care) 24 hours a day. These are both truisms that are repeated by both clinical and corporate sides of the aged care sector. Like intractable sectarian disputes, these two perspectives are hurled back and forth, with compromise a faint possibility.
The key, however, IS compromise.
Families must accept that group-living in residential aged care can never be the same as care from a loved one in the person’s own home. The very care and behavioural issues that led to the need for residential aged care will almost always become amplified in unfamiliar surroundings, living among strangers, having physical needs met by others. It is difficult enough to ensure that there are enough skilled clinical staff present at all times, let alone superspecialised aged care psychiatry resources. And in the middle of the night? No chance.
At the same time, our community needs to accept that more needs to be done. If we expect better management of difficult behaviour, education of staff is not enough – skilled clinicians must be provided, with the time to implement recommended techniques. Back-up must be available at all times of day and night – the cognitively impaired, frequently confusing day and night, might not save their difficult behaviour for office hours, when the consultants attend. And staff should not have to endure the verbal and physical aggression as inevitable – they must be both protected and recompensed for these risks in their work environment.
Are we, as a community, prepared to pay for these changes? If not, then the reactions to the Royal Commission revelations can only be described as faux indignation.
We can be judged, as a community, by the way we care for our children and our elderly. We have no right to judge others, however, unless we stand in their shoes. Unless we work together to find the appropriate compromise between care, safety and cost, we are complicit in the shortcomings. Outrage is no substitute for action, and understanding must replace blame.
Dr Sue Ieraci is a specialist emergency physician. After 35 years in the public hospital system, she now works in telemedicine and health system consulting. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She is an executive member of Friends of Science in Medicine.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Moral outrage, expressed by individuals with direct experience of residential aged care in Australia and made public, can lead to positive change. The Royal Commission into Aged Care Quality and Safety has provided an opportunity for a small number of aged care residents to provide evidence to the Commission. The majority of residents are cognitively impaired and have little autonomy over their day to day lives. Video cameras become important when older persons are unable to speak out about the care they receive.
We have seen improvements in residential aged care, and in the willingness of the accreditation bodies to call out poor care since the Royal Commission was announced. Advocates for quality care are looking to the Commission to ensure that improvements are sustained beyond 2020 and residents have access to skilled, compassionate and effective health and end of life care in the setting of their choice.
Far more trained staff in aged care facilities , taught compassion care and respect for the elderly . They must be able to communicate and understand the needs and often humilitating situations the elderly find themselves in .Activities should not be restricted to an hour a morning 5 days a week . The elderly should have access to a wide variety of areas , indoors and outdoors eg TV and movie room , music room , art room , outdoor area they can access and feel involved in .not just an activities room !
We need far more ‘ village ‘ like facilities with independat living units with access to dinning , medical care etc , with transition to aging in place .
Age catches up with everyone ! Think what you would like not only for your loved ones but for yourself !
Child care workers and aged care workers are invaluable to our society , they deserve respect and higher wages so we can attract mor genuine caring people , both male and female into these career areas .
There is much more at play than the “Triple Jeopardy of advanced age, cognitive decline and mental illness”. There is the incontrovertible fact that they suffer from a chronic progressive illness that is ultimately fatal as well as other serious chronic illnesses that contribute to the presentation and complicate the management. Treating the BPSDs as complications simply means that we have failed to identify all of the manifestations of the cognitive impairment at the time of the initial diagnosis.
Some of the manifestations, such as depression, anxiety, psychotic disorders, can be viewed as identifiable mental illnesses in their own right and can be diagnosed when we are consulted to assist in the management of a behavioural disorder and treated in the same way as depression, anxiety and psychotic disorders at any age.
Residents in Aged Care Facilities are discriminated against by having minimal access to needed health care that is their right and would be available to them if they remained in the community.
Their sin is requiring 24-hour expert HEALTH CARE. There is no way that the Aged Care Industry will ever be able to offer anything approaching the level and quality of the HEALTHCARE that they need while providing accommodation under a business model.
The ABC’s vote compass indicates a growth in support for voluntary euthanasia to nearly 90% of Australians. As an aged care practitioner for many decades, this support correlates with the transition of residential care from nursing to so called personal care as driven by neo-liberalism. Minimum standards required of personal care assistants can never substitute for the care provided by properly trained, selected and supported aged care professionals given the complexity of the work.
Sue, as always is correct in her appreciation of the problems especially from her perspective of dealing with residents in the “too hard basket”. It is fairly obvious even now that the recommendations of the Royal Commission can be anticipated and that implementing them will be very expensive.
There is abundant evidence of the benefit of appropriate music therapy for residents with dementia. This usually involves limited sessions with an individual therapist or in small groups, effective but also relatively expensive.
Australia, has a service, unique in the world, broadcasting age-relevant entertainment via satellite to aged care facilities Australia wide, 24/7. It was conceived as simply entertainment to brighten the lives of elderly, socially isolated folk. There is independent evidence of its benefit in dementia and improving the quality of life for residents in general. It is called Silver Memories and broadcast by volunteers at community broadcaster 4MBS in Brisbane. It is not a “cure all” but appears to be very beneficial and inexpensive.