Palliative care and end-of-life care | Aged Care Quality and Safety Commission

What is the outcome you need to achieve?

The provider must recognise and address the needs, goals and preferences of individuals for palliative care and end-of-life care, and must preserve the dignity of individuals in those circumstances.
The provider ensures that the pain and symptoms of individuals are actively managed, with access to specialist palliative and end-of-life care when required.

The provider must ensure that supporters of individuals and other persons supporting individuals are informed and supported, including during the last days of life.

Updates to guidance

An updated version of the strengthened Standards was published by the Department of Health, Disability and Ageing on 18 February 2025. Please see here for more information Strengthened Aged Care Quality Standards – February 2025 | Australian Government Department of Health, Disability and Ageing.

The Commission is currently updating our guidance content to reflect these changes. Please ensure you check back regularly.

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5.7.1

The provider has processes to recognise when the individual requires palliative care or is approaching the end of their life, supports them to prepare for the end-of-life and responds to their changing needs and preferences.

5.7.2

The provider supports the individual, supporters of the individual and other persons supporting the individuals and substitute decision maker, to:

continue end-of-life planning conversations
discuss requesting or declining aspects of personal care, life-prolonging treatment and responding to reversible acute conditions
review advance care planning documents to align with their current needs, goals and preferences.

5.7.3

The provider uses its processes from comprehensive care to plan and deliver palliative care that:

prioritises the comfort and dignity of the individual
supports the individual’s spiritual, cultural and psychosocial needs
identifies and manages changes in pain and symptoms
provides timely access to specialist equipment and medicines for pain and symptom management
communicates information about the individual’s preferences for palliative care and the place where they wish to receive this care to aged care workers, supporters of individuals and other persons supporting individuals
facilitates access to specialist palliative care and end-of-life health professionals when required
provides a suitable environment for palliative care
provides information about the process when an individual is dying and about loss and bereavement to supporters of individuals and other persons supporting individuals.

5.7.4

The provider implements processes in the last days of life to:

recognise that the individual is in the last days of life and respond to rapidly changing needs
ensure medicines to manage pain and symptoms, including anticipatory medicines, are prescribed, administered, reviewed and available 24-hours a day
provide pressure care, oral care, eye care and bowel and bladder care
recognise and respond to delirium
minimise unnecessary transfer to hospital, where this is in line with the individual’s preferences.

Why is this outcome important?

The clinical care* that a person receives in the last years, months and weeks of their life can reduce their distress and grief around death and dying. Safe and high-quality care at the end-of life* is comprehensive*, coordinated care* (Outcome 5.4). All older people have the right to dignity, comfort and privacy and to be cared for respectfully and with compassion. Preventing and giving relief from suffering is the highest priority. Like dementia* care, palliative care* and end-of life* care is core business for providers.

Care at the end-of-life* is evidence-based*, clinically appropriate and timely*. Using a person-centred* approach, the older person is supported to:

identify their needs and goals
understand information
make choices and decisions about their care.

Workers and health professionals* recognise and respect older people’s values, needs and wishes and provide care that responds to and meets their preferences. Substitute decision-makers*, family members and carers are involved in making decisions in line with the older person’s wishes. This also needs to meet state or territory legislation (Outcomes 1.1 to 1.3).

An important part of Outcome 5.7 is recognising when an older person has a condition that is life limiting or they’re approaching the end of their life. Also, recognising when palliative care* can benefit them. Health professionals* need knowledge, sensitivity and skill to have conversations about advance care planning, palliative care and dying. The older person should be supported to have end-of-life* care conversations to the extent that they choose. Their choices must be respected. You should have processes* to review advance care planning* documents with the older person to ensure they are in line with their wishes and current needs, goals and preferences*.

Effective communication and working together is important to make sure there is continuity of care. This also helps to coordinate care between teams, different settings and at transitions. Not all older people will need specialist palliative care* services. However, there should be processes to identify when an older person would benefit from specialist palliative care* and to facilitate timely* access to it.

Quickly recognising when an older person’s is approaching the end of their life and their needs are changing is critical. Providers have processes* to monitor, manage and escalate changing needs and symptoms. The focus may be on the person's needs and identifying multidisciplinary team members to meet these needs which may include support medication management* and timely* access to medications when necessary.

Note: Outcome 5.7 includes principles from the:

National Palliative Care Strategy, National Consensus Statement: Essential elements for safe and high-quality end-of-life* care
National Palliative Care Standards for All Health Professionals and Aged Care Services.

Service context considerations

Residential service providers have 24-hour responsibility for the clinical care* needs of the people in their care. All the actions and key tasks in this outcome apply to residential service providers.

Home service providers have systems* to manage risks to people receiving care that is in proportion to:

how complex the person’s needs are
the type of service they provide
where they deliver the care.

They work with the older person, carers, health professionals* and specialist palliative care* services and others. This helps providers to understand what is needed and agree on the care they can provide and what is provided by others.

Update to guidance

The Commission is currently updating our guidance content to reflect these changes. Please ensure you check back regularly.

Key tasks

Providers(active tab)

Providers

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 service context

Residential and home service providers

To recognise and get ready for a person’s end-of-life*, all providers need to build on their systems* and processes* for:

person-centred care* (Outcome 1.1)
assessment and planning (Outcome 3.1)
comprehensive care* (Outcome 5.4).

Home service providers

The role of home service providers is in proportion to:

the type of services
how complex the services are
where they deliver the services.

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 service context

Residential and home service providers put in place person-centred* processes* for end-of-life* planning. These processes should be in proportion to the:

type of services provided
how complex they are.

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 service context

All residential and home service providers put in place processes* for comprehensive end-of-life* care. These processes* should be in proportion to the:

type of services provided
how complex they are.

Residential service providers

Residential service providers need to put in place processes* to support fair access to community and inpatient services. These are available to older people living in their own homes. This includes access to specialist palliative care* services when needed.

Home service providers

Home service providers should consider assessing the person’s carer* if they have one. The assessment should look at the carer’s needs, what they’re able to do and if they can keep supporting the older person long term.

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*.

Outcome service context

Residential and home service providers

Residential and home service providers put in place processes* for care at the end of a person’s life that are in proportion to the:

type of services provided
how complex they are.

Home service providers

Home service providers need to make sure each older person has a plan in place for the safe use of medicines* to manage pain* and symptoms, including anticipatory medicines* in line with their service context and the services being delivered. Everyone involved should understand the roles and responsibilities* of:

the provider
carer*
family
substitute decision-maker*
health professionals*.

Ensure that roles and responsibilities for care and escalation are clearly documented to support the older person during the last days of their life. Make sure escalation processes* are available 24-hours a day in line with the service context and the services being delivered.