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THE forensic investigation into the past systemic failures of Australia’s aged care sector is a major focus of the Royal Commission into Aged Care Quality and Safety and, perhaps unsurprisingly, the most attention grabbing, but it is just one avenue of enquiry under the Royal Commission’s terms of reference.
Arguably, just as important are the Royal Commission’s inquiry, deliberation and subsequent recommendations for the future of aged care services in Australia.
That work is well underway. Released late in August, but garnering scant media attention, was the eighth such study that will help underpin those recommendations; a report commissioned by the Royal Commission titled International and national quality and safety indicators for aged care.
Palliative Care Australia (PCA) welcomes the report, but the surprising feature of the study is not what is contained within its 189 pages, but rather what has been left out: a necessary focus on palliative care.
Prepared by the South Australian Health and Medical Research Institute (SAHMRI), the report is a first step in addressing a current gap in the aged care system – a paucity of evidence-based quality and safety indicators – one labelled by the Royal Commission as “unacceptable”.
Currently, Australia has a limited program of quality indicators for residential aged care. Since 1 July 2019, residential aged care providers have been required to report on pressure injuries, use of physical restraint and unplanned weight loss. But if Australia is to better ensure that “aged care services are of high quality and safe” as per the Royal Commission’s remit, there must be a more comprehensive program of indicators across all aged care programs. Along with improving the standards that address the accreditation and assessment of individual facilities and providers, we must also adopt a set of indicators that provide us with the bigger picture: indicators that tell us how the aged care sector is performing across states, the territories, regions and nationally.
That’s exactly what the SAHMRI study examined, concluding that an independent body is set up to oversee quality monitoring and reporting in Australia and stating that “a well-designed, comprehensive, and effective quality and safety indicator reporting system can be implemented to capture important indicators of care that will inform and ultimately improve health and wellbeing outcomes for Australia’s older population”.
Notably, SAHMRI found that a wide range of quality indicators can be produced from existing data without any burden to aged care providers.
Still, the absence of specific palliative care indicators in nearly all the 11 countries examined is a concern.
The recommended indicators have a strong focus on issues such as medications and pain management, wound care, care plans, nutrition and weight loss, hospital admission and falls and fractures. In several instances, the data collected actively excludes palliative care patients.
The only country with any palliative care indicators is Sweden and these indicators are very narrow in their scope. Sweden collects data on the share of persons deceased at age 65 years or older who before death had a conversation in which they were informed about their situation, as well as data on the percentage of persons deceased at age 65 years or older who had an assessment of pain during their last week in life.
More useful would be the collection of data that highlighted what level of access residents in residential aged care facilities had to specialist palliative care.
Another valuable metric is the number of avoidable hospital admissions and/or avoidable incidence of non-beneficial care by older people receiving palliative care.
With the inclusion of these, together with other valuable and meaningful metrics, Australia has the opportunity to lead the world in the development of a suite of robust quality palliative care indicators.
A reminder, if one was even needed, came in a follow-up article published by the Royal Commission late in August, which found that without meaningful investment in aged care services, monitoring of standards and quality indicators will only get us so far.
Conducted by the University of Queensland, Access Research Paper 9 – The cost of residential aged care, found that higher funding was needed for residential aged care just to meet basic standards. Even more funding was needed for reform to achieve high quality care in Australia.
Palliative care is a critical component of aged care and cannot be overlooked.
Speaking to the media in July the Prime Minister Scott Morrison acknowledged as much, stating: “The nature and demands on our aged care services have changed”, and reminding Australians that people are entering residential aged care with more complex and chronic conditions than in the past, and with many likely to require palliative care.
In our submissions to the Royal Commission, PCA has consistently called for the existing Aged Care Quality Standards to specifically include palliative care. PCA has already invested heavily in this space, releasing in 2018 the National Palliative Care Standards (Edition 5) following consultation with the palliative care community and other stakeholders. PCA is also engaged in the development of a supplementary standard for generalist palliative care
Just as important, the much-needed new system of reporting against quality indicators must also include specific indicators that can support access to quality palliative care, when and where it is needed.
Professor Meera Agar is the Chair of Palliative Care Australia.
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.
We need to provide education to nurses and support workers in EoLC provision as this is the only way the residents in Aged Care will be able to receive holistic care. I was witness to a resident who was supposed to be receiving palliative care and even though the GP and Nurse Practitioner had set up a palliative care plan with medication management for on-going breakthrough pain, the nursing staff did not give the appropriate medication.
Education… Education… Education…
Nursing staff acquired in RACF are not equipped with the knowledge to administer large doses of opioid medications to residents who are dying in pain because most of them have not done placements or been employed in the hospital systems and/or they don’t have time due to their workload.
Where are the priorities in RACF… paperwork to keep the funding or holistic care for the residents??
A very kind ,considerate and concerned write up.. very much admire the inspiration and nobility of Madam Meera…God bless you and all unto this noble task or much better to say the door open to happiness peace oneness and bliss for all.God bless all
Personal experiences can tell us a lot about quality of care and the Royal Commission into Aged Care Quality and Safety has yielded rich evidence about the quality of palliative care across Australia. The Interim Report describes the provision of palliative care in aged care as “patchy and fragmented”. This is an unacceptable situation.
Additional funding is available for end of life care in residential aged care and it is reasonable to expect that this translates to the provision of quality care. Quality indicators have the potential to increase stakeholder engagement and planning to ensure that all residents receive appropriate care at the end of life.
Quality palliative care is possible in residential aged care and some do it very well, many don’t. There are some residential aged care facilities that don’t even have a syringe driver if they need it.
Palliative care is quality when pain and symptoms are managed well and the family is engaged in the care if that is appropriate. It requires comprehensive assessment of symptoms, education of staff, patient and families, mentorship, a culture of learning and teaching, doctors who don’t mind being phoned at night, nurses who have the knowledge and confidence to communicate the patient’s palliative care needs to the doctor and advocate for the patient. It’s the responsibility of all the health professionals to collaborate to make palliative care and end of life care as comfortable and personalised as possible for the patient.
Experienced and educated nursing staff, anticipatory prescribing and access to pall meds on imprest is key to patients avoiding being sent to ED.
My Dad was in Aged Care for a few months only, as he’d already received a terminal illness diagnosis. The visiting GP organised a group phone call to all the family, including one overseas. This was to explain the palliative process. Two nurses on staff had additional palliative care training. There was a separate palliative facility next door (both Catholic institutions), but they were able to bring palliative care to Dad’s room. This worked well, with staff phoning GP to prescribe medications. However the GP said the staff could ring him “during the day,” which is understandable, but I don’t know the situation if it were during the night time. We, and Dad, were lucky in that he needed additional medications during the day, and died mid-afternoon. I say, “we were lucky;” it shouldn’t be a matter of luck. That said, Dad’s treatment overall was excellent and the aged care place also excellent.
One quality indicator for palliative care in RACFs would definitely have to be around anticipatory prescribing (or lack thereof). The onus also rests on the visiting GP in regards to this, not just the RACF staff. Therefore any quality indicators would have to encompass the responsibilities of the entire multidisciplinary team.
I have experienced the death of my mother in an aged care facility and I felt the care was fantastic. The imminent death was discussed and a plan put in place that was followed. The nursing care was very intense, with presure care turns every 2 hours, even if they fell at mealtimes for other residents. The care of the family in this time was also exceptional. I do agree proper palliative care is essential and can be done well.
Yes, but it’s quicker and easier for nursing homes to phone for an ambulance and send them to an Emergency department so that the ED can manage the elderly person’s death. sigh !