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.
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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