Outcome 5.7.1

Put in place processes* for recognising and preparing for palliative care* and the end of life* needs.

• Put in place person-centred*, culturally safe* processes* (Standard 1) to recognise older people who are approaching the end of their life. As well as those who could benefit from palliative care*. These processes* can include:
  • supporting workers and health professionals* to use risk prediction tools, trigger tools and questions
  • communicating with the older person, their carers* and family to identify signs they may be approaching the end of their life (Outcome 1.3)
  • identifying and managing acute deterioration* that may be able to be reversed in line with the older person’s wishes.
  • involving the older person’s GP or nurse practitioner in discussions about diagnosis and prognosis as the older person approaches the end of their life.
• Facilitate access* to health professionals* to review medication to look at whether the older person’s medications should be de-prescribed* or stopped. As well as looking at safe ways to administer medication. This is done is discussion with the older person and in line with their goals of care*.
• Plan for anticipatory medicines* and put in place processes* for safe use and administration (when needed).
• Plan for and facilitate access* to equipment, aids and devices. Make sure that workers, health professionals* and carers* are trained and confident using them.
• Make sure that workers have the knowledge and skills they need and can confidently recognise when an older person is approaching the end of their life. They also need to be able to perform their role within their scope of clinical care* and where they deliver care.

Monitor, review and continuously improve how your organisation recognises palliative care* and end-of-life*.

• Collect and analyse data from evaluation, reviews and feedback*. Use this to improve how you and your workers recognise and respond to care needs at the end-of-life*.
• Look at feedback* about the experiences of older people, substitute decision-makers*, carers* and family about how you and your workers supported them to prepare for end-of-life*.

Outcome 5.7.2

Put in place processes* for end-of-life* planning.

• Build on the organisation’s systems* and processes* for:
  • person-centred care* (Outcome 1.1)
  • dignity, choice, independence and quality of life* (Outcomes 1.2 and 1.3)
  • assessment and planning (Outcome 3.1)
  • comprehensive care* (Outcome 5.4).
• Put in place processes* for end-of-life* planning and making decisions that:
  • are culturally* and psychologically safe*, trauma aware and healing informed*
  • support the older person to have ongoing end-of-life* planning conversations with workers, health professionals* and others. The planning and conversations should be in line with the older person’s preferences. For example, including substitute decision-makers*, carers* and family in these conversations.
  • include reviewing advance care planning* documents with the older person in line with their preferences.
• Workers and health professionals* are trained and supported have end-of-life* conversations that are person-centred*.
• End-of-life* planning conversations should seek to find out what is important to the older person at the end of their life, including the place the older person would wish to be at the end of their life.
• Include the older person’s GP or nurse practitioner in discussions about diagnosis, prognosis and options for a coordinated* planning and delivery of end-of-life* care.
• Assist the older person to make their own decisions with supported decision making*, when needed.
• Communicate with the person’s substitute decision-maker* when an older person lacks capacity to take part in making decisions.
• Make sure policies* and processes* for advance care planning documents* and substitute decision-making are in line with your state or territory legislation. Workers and health professionals* also need to understand these.
• Store and manage advance care planning documents* securely (including appointments of a substitute decision-maker*). This makes sure they can be easily accessed and regularly* reviewed, while maintaining privacy.
• Share current advance care planning documents* when needed with the older person’s consent, particularly:
  • at transitions of care*
  • with paramedics on transfer to hospital.
• Explain to older people that, with their consent, their advance care planning documents* can be uploaded to My Health Record*.

Monitor, review and improve processes* to support older people at the end of life*.

• Monitor how well your organisation is supporting advance care planning* in everyday practice. This includes advance care planning* reviews and assessment on:
  • how you receive, store and manage advance care planning documents*
  • how you review, follow and share with health professionals’* advance care planning documents*
  • how you manage and share advance care planning documents* to ensure relevant health professionals and services have access when needed, such as during transitions of care*.
• Analyse feedback* from older people about the quality of end-of-life* planning conversations.
• Consider how effective your processes* are for supported decision-making* when an older person’s capacity to make decisions about their own care is reduced.

Outcome 5.7.3

Put in place systems* and processes* for comprehensive palliative* and end-of-life* care.

• Plan and provide person-centred*, culturally safe*, trauma aware and healing informed care*. Make sure care meets an older person’s goals, preferences and wishes (Outcome 1.1).
• Plan and provide comprehensive assessment that looks at the whole person. Assessment that focuses on comfort, dignity and effective pain management* to prevent and relieve suffering (Outcome 3.1 and 5.4). Comprehensive care* at the end of a person’s life responds and adapts to changes in their clinical needs. These changes can include periods where the person deteriorates*, stabilises and sometimes improves.
• Review the older person’s preferences about who they want involved in their care and how they want them involved. This might include substitute decision-makers*, carers*, family, spiritual leaders and others (Outcome 1.1).
• Partner with the older person to identify their cultural, spiritual and psychological needs on commencement of services and on an ongoing basis. These needs can be as important to them as their physical needs (Outcome 1.1). This can include considering the older person’s beliefs and practices around death and dying.
• Identify where the older person prefers to receive palliative care* and where they prefer to die. Strategies and interventions should support the older person to stay at home, or where they prefer to be at the end of their life.
• Aboriginal and Torres Strait Islander people may want to die on Country. Collaborate with community members on these decisions, in line with the person’s wishes.
• Provide information to family and carers* about the dying process*, grief, loss and bereavement*.
• Make sure that workers and health professionals* understand their role in providing comprehensive care* for older people with palliative care* needs and at the end of their life. They also need the knowledge and skills to provide high-quality care.
• Put in place and maintain relationships and referral pathways with health professionals*, and specialist palliative care services.
• Make sure workers quickly identify, monitor and escalate a change or deterioration* in an older person’s health.
• Make sure your organisation and workers communicate early with health professionals*, substitute decisionmakers*, carers* and family as needed. Follow the older person’s preferences.
• Facilitate timely* access to specialist palliative care* and other services when needed.
• Facilitate timely* access to medicines* . Medicine reviews* should optimise symptom control and include anticipatory* prescribing and deprescribing* to optimise symptom control (Outcome 5.3).
• Facilitate timely* access to specialist equipment for an older person with palliative care* needs and at the end of their life.

Monitor, review and improve systems* and processes* for comprehensive palliative* and end-of-life* care.

• Analyse your clinical data on how effectively you’re treating symptoms, including the use of pain* relief.
• Review feedback* from older people, substitute decision-makers*, family, carers* and health professionals* to make your processes* for comprehensive care* at the end-of-life* more effective.
• Monitor how and when workers refer and escalate care palliative care* needs to health professionals* and specialist palliative care* services. Work to improve access and reduce barriers where needed.

Outcome 5.7.4

Put in place processes* for the last days of life*.

• Building on systems* for person-centred*, comprehensive end-of-life* care (Outcomes 1.1, 5.4 and 5.7), put in place processes* to:
  • identify when an older people is in the last days of their life*. This may include using comprehensive assessment triggers and assessment tools.
  • support person-centred care* and shared decision making* with the older person for care in the last days of life*. This can include decisions about transfer to hospital, stopping interventions that are not beneficial and avoiding futile interventions like CPR (Outcome 1.1).
  • focus on maintaining comfort and dignity. Plan for and manage distress, discomfort and the possibility of severe symptoms.
  • make sure you have systems* for communicating with older people, carers*, family, substitute decision-makers* and escalating to health professionals* in the last days of life* (Outcome 3.4)
  • monitor, manage and escalate quickly changing needs and unresolved symptoms for medical review. This might include a specialist palliative care* service.
  • address the increased risk of delirium*, pressure injury* and the need for more oral, eye, bowel, bladder and pressure area care.
• Make sure that anticipatory medicines* to manage pain* and symptoms are:
  • available
  • appropriately prescribed, administered, monitored and reviewed
  • available 24-hours a day (Outcome 5.3).
• Make sure workers are trained, skilled and supported to identify when an older person is in the last days of their life*. Also, being able to provide comprehensive end-of-life* care. This includes assessing and responding to symptoms that may have a reversible cause such as delirium*.

Monitor, review and improve processes* for the last days of life*.

• Analyse feedback* from substitute decision-makers*, family and carers* of people who received care in the last days of life*. Use this information to improve systems* and processes*.
• Analyse audit data such as investigations, interventions and transfers of care in the last days of life*.