We recently tuned in to a webinar hosted by End of Life Directions for Aged Care (ELDAC). The webinar, entitled “What Age Care Providers Need to Know About Older Australians and End of Life Care” showed a panel of clinical experts sharing valuable information and raising key considerations to assist facilities in the context of the COVID-19 pandemic.
For those who don’t have time to watch the full webinar, or just want a quick summary, we’ve highlighted the key points below.
COVID-19 and End of Life Care: What are the Key Issues?
Needs of Care vs Available Resources
Resources include “Stuff”, “Staff” and “Systems”. For many aged care homes, managing the threat of COVID-19 has resulted in shortages in some or all of these resources. The main question is: how can we best use our resources to maximise the overall benefits of care?
Advance Care Planning
Providers are being urged to include advance care planning in their planning and management of COVID-19. There are many benefits to advance care planning, but only 25% of older Australians aged 65+ years have documented their preferences in an Advance Care Directive.
Managing Resources: Tips and Considerations
Is there enough equipment, medicines and space? What do we need? What are we likely to have an increased demand for and under what circumstances? What is currently available?
- Place stock orders in accordance with the stock check.
- Don’t stockpile. it’s not necessary and can deprive other providers of products that may be essential for their current care and service delivery.
- Consider having medical practitioners write medication prescriptions pre-emptively in case of emergencies or where you know such medications will be needed (such as when medications are required by particular consumer needs or palliative care or end of life plans). Such medications can be ordered as PRN medication or as required. They should be used only in such circumstances as indicated and documented by the prescriber.
- Prepare a medication/equipment trolley for end of life care. Consider what would be required to address both the medical and psychosocial needs of consumers.
Consider the Broader Context and Avoid Blanket Rules
When it comes to allocating resources, strict protocols or blanket rules – such as an age limit as the criteria for resource allocation – aren’t helpful. The goal of care should be to maximise the quality and beneficial effects of health care with the resources available. When allocating resources, you should consider the systems and operational processes across the home, as well as the knowledge, skills and capabilities of your workforce.
Assess your Workforce
You need to assess your current workforce and use the outcomes of this assessment to plan ahead. As part of your assessment, consider:
- End of life – who is available to plan and provide end of life care and support? Consider both internal staff and external organisations.
- Palliative care expertise – which consumers are most likely to need palliative care? Who can provide palliative care both within and outside the facility? Would they be available if an COVID-19 outbreak occurred? How would they be accessed?
- Human resources – have a plan to mitigate staff shortages (consider a loss of staff of up to 30% of current workforce). Consider also whether you need extra staff to provide infection surveillance or other specialist care during a pandemic (e.g. dementia care).
- Training and competencies – staff should have a strong understanding of infection control procedures and the practical application of these required practices. Things as basic as handwashing best practice, appropriate use of PPE and cough and sneeze etiquette can easily be forgotten – frequent refreshers (at least annually and in the current circumstances more frequently) can ensure ongoing vigilance and adherence to the required standards of these procedures.
- Clinical practices – ensure nursing staff are confident in identifying and managing the symptoms of COVID-19, including identifying suspected cases of coronavirus and responding to confirmed diagnoses.
Assess your Current Systems and Day-to-Day Operations
What systems are in place to ensure that day-to-day operations continue to run as usual while minimising the risk of an outbreak within the facility? What systems need to be reviewed and changed? Some key areas to consider are:
- Medical reviews – can you use remote health consultations rather than in-person?
- Medication prescribing – where appropriate, use electronic medication order systems (Note: there are upcoming legislative changes to e-prescribing, which ACE will be keeping an eye on)
- Medication availability – use an Imprest medication system in line with state/territory medication legislation and requirements; maintain a good relationship with a supplying pharmacy and make sure they have capacity to fulfil medicine orders in a timely way, including out of hours, especially in emergencies.
Other Things to Consider
- Infection Control – assess and monitor the ongoing effectiveness of policy and procedures. It is crucial to have an Infection Control Coordinator who understands infection control processes and can implement an Outbreak Management Plan.
- Deterioration – clinicians should have documented procedures and consumer plans for managing cases of deterioration.
- End of life care – have guidelines for symptom management, palliative care and care of the body after the death.
- Communication – ensure communication can be maintained with all key persons. Keeping families of consumers updated and providing opportunities to have open conversations can make a huge difference during COVID-19 restrictions. Remember that these conversations need to include specific updates about the individual consumer’s health and well-being – family members can’t observe this for themselves.
Advance Care Planning (ACP) and Advanced Care Directives (ACD): Tips and Considerations
Make sure any existing ACPs and ACDs are up to date, available and stored in the consumer’s health record.
Where consumers do not have a current ACP or ACD:
- promote the processes associated with ACP within the Home and throughout key care review occasions (e.g. admission, case conferencing)
- provide encouragement and information to help the consumer discuss their future health care preferences with their representatives, family members and their treating medical practitioner
- identify and record the consumer’s substitute decision-maker. This should be made known to all staff who participate in the delivery of the consumer’s care and services
- for new residents, arrange a pre-admission interview with the consumer and their family members. This creates an open and communicative relationship between all parties and is a good way to get an overall picture of the consumer, find out what they want out of their care and start the conversation about advance care planning.
Consultations, and completing and signing documents can be more difficult under COVID-19 restrictions. If possible, utilise email or fax to get the documents completed and signed. Where email/fax is not an option, a consumer can verbally express their end of life care preferences while they still have decision making capacity. A record of a verbal expression in the consumer’s notes can be enough to direct end of life care (Note: these kinds of directives are known as “common law ACDs” which are legally recognised in all states except QLD, VIC and SA. The validity of common law ACDs is murky in these states.)
The final message is that palliative and end of life care is already a core part of aged care so the best place to start is just to “go back to basics” and remember that preparation is key.
The ELDAC website is packed full of valuable tools and resources. In particular, their resources for:
- Advance Care Planning - https://www.eldac.com.au/tabid/4971/Default.aspx
- Assessing Palliative Care Needs - https://www.eldac.com.au/tabid/4973/Default.aspx
- Providing Palliative Care - https://www.eldac.com.au/tabid/4974/Default.aspx
- Responding to Deterioration - https://www.eldac.com.au/tabid/4976/Default.aspx
- Managing Dying - https://www.eldac.com.au/tabid/4977/Default.aspx
- Bereavement - https://www.eldac.com.au/tabid/4978/Default.aspx
The SPICT Tool was also recommended as an assessment tool to recognise deterioration and end of life: http://www.spict.org.uk/the-spict/
ELDAC is also welcoming phone and email enquiries:
Phone - 1800 870 155
Email - Eldac.firstname.lastname@example.org
The staff behind Aged Care Essentials are here to support you through these trying times. We are open to questions and requests for information. Please let us know any suggestions you may have using the form below.