clinical focus
A palliative approach
What does the coronavirus
pandemic reveal about
palliative care in RACFs?
By Sara Karacsony and Melissa Bloomer
Across the world, the greatest
number of COVID-19 deaths have
been in older people, with many
residents in residential aged care facilities
(RACFs) at risk of the disease.
The complex health needs associated
with multimorbidity and frailty contribute
to this risk. The hands-on provision of
much of residents’ personalised care
makes it impossible for residents and aged
care workers to abide by social distancing
recommendations. The home-like nature
of aged care settings, where residents
share common areas and facilities,
including bathrooms, also contribute to the
increased risk of COVID-19 transmission. 1
Given the high incidence of cognitive
impairments such as dementia in RACFs,
supporting residents to self-isolate to
minimise risk, yet not cause social isolation
and distress, is also immensely challenging.
Caring for dying residents is a core
part of care in RACFs, and the pandemic
highlights why palliative care – including
facilitating conversations about a resident’s
goals of care, and advance care planning –
is more important than ever.
How or when an older person should
be transferred to an acute care facility
for treatment if symptoms become
severe is a further challenge, as this may
not align with the person’s expressed
wishes or preferences for care. Pragmatic
decisions about the extent of treatment in
acute care may also be necessary when
resources are limited.
Notwithstanding the importance of
infection prevention and control, a broader
focus and emphasis on the provision of
palliative care as part of routine care in
RACFs must not be forgotten.
A palliative approach to care, which is
considered best practice for older people
with life-limiting illnesses, including the
growing number of people living with
advanced dementia, can ensure symptom
relief, optimise comfort and provide
support to families. 2
As the number of COVID-19 deaths
continues to climb, it is clear that all aged
care workers need access to palliative care
education and training.
Appropriately skilled staff are essential to
provision of care during the crisis. Where
possible, continuity of care should be
prioritised as a strategy to minimise change
for the older person. Similarly, adequate
resources are needed so that registered
nurses in aged care can manage symptoms
to alleviate end-of-life discomfort and
protect against residents dying in pain or
from experiencing breathlessness.
Emotional support for residents is also
good palliative care, as is the support of
families in their grief, before and after
death. When face-to-face family visits are
not possible, the use of technology can
be encouraged and facilitated to enable
families to hold a ‘virtual vigil’.
While not the same as being there in
person, enabling family to ‘be with’ and
talk to the dying older person is likely to
provide significant comfort to all involved.
Bereavement support, which is considered
an essential element of palliative care,
should still be provided in ways that abide
by social distancing rules. Subsequent
memorial services can be arranged later
to enable families of COVID-19 victims to
gather and commemorate the older person
and their life, when it is safe to do so.
However, a palliative care approach
is not feasible in all aged care settings
without immediate consideration of the
workforce implications. Aged care workers
need extensive education to ensure they
have the requisite skills, knowledge and
resources to facilitate this level of care for
older people approaching end of life.
In addition, psychological and teamwork
supports must be established to equip
aged care workers for their role in caring
for the dying, challenging assumptions and
attitudes towards death and the provision
of end-of-life care.
Given that aged care is already a
high mortality industry, the impact
of COVID-19 may see workers
overwhelmed with multiple deaths.
Self-care is vital, accompanied by social
and emotional support strategies for
aged care workers.
Long-term preparation strategies that
include embedding palliative care into
the educational curricula of all healthcare
professionals has been a recommendation
of the Australian and international palliative
care community for many years.
The Australian government has funded
an ongoing project since 2003. 3 It has been
suggested that the healthcare workforce
would have been better equipped to deal
with the suffering caused by this pandemic
had this recommendation been heeded. 4
A similar focus is essential for the aged
care workforce, the majority of whom
are unregulated workers, with fewer
opportunities for formal palliative care
education, despite the high need in RACFs.
In response to the COVID-19 crisis, the
Royal Commission into Aged Care Quality
and Safety has acknowledged the urgency
of identifying new and increased workforce
and resource needs in aged care. 5 Included
in these must be the support of the aged
care workforce to provide much needed
palliative care for older people in RACFs
who are most at risk of dying. ■
For references go to
www.agedcareinsite.com.au
Sara Karacsony, PhD, RN, is a lecturer in
nursing in the School of Nursing at the
University of Tasmania. Melissa Bloomer
PhD, RN, is an associate professor of
nursing in the School of Nursing and
Midwifery at Deakin University.
20 agedcareinsite.com.au