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Home Care Clinical Care Assess Your Knowledge Organisational SupportResidential Aged Care Assess Your Knowledge Clinical Care
- Advance Care Planning
- Recognise End of Life
- Assess Palliative Care Needs
- Provide Palliative Care
- Work Together
- Respond to Deterioration
- Manage Dying
- Bereavement
End of Life Law Toolkit Capacity and Consent to Medical Treatment Factsheet: Advance Care Directives Futile or Non-Beneficial Treatment Legal Protection for Administering Pain and Symptom Relief Managing Disputes about Medical Treatment Decision-Making Substitute Decision-Making Urgent Medical Treatment Voluntary Assisted Dying Withholding and Withdrawing Life-Sustaining Medical Treatment Overview of End of Life Law in Australia Advance Care DirectivesHome Care Residential Aged CareAssess Your Knowledge Clinical CareEnd of Life Law Toolkit Dementia Toolkit Education Other ToolkitsAdvance Care Planning Recognise End of Life Assess Palliative Care Needs Provide Palliative Care Work Together Respond to Deterioration Manage Dying BereavementOrganisational SupportWork Together
Working as a team means providing integrated care for the older person and their family and carers. This will require sound relationships and cooperation across services, including residential care, acute care, primary care and specialist palliative care.
Working together is vital as it supports the quality and continuity of care for older people with end-of-life needs. Continuity of care means that:
- Relevant information is appropriately exchanged between involved providers of care.
- The preferences, values, and care needs of the older person are known and respected, which inform care.
- Care is coordinated smoothly and collaboratively.
Which people and services are essential to working together in RAC?
People identified by the person as family. This may include people who are biologically related, however it may not. Other people that may be identified as family include:
- those who joined the family through marriage or other relationships, such as kinship
- chosen family
- street family for those experiencing homelessness
- friends
- pets. [1]
Primary Care Providers are health services, health professionals and workers. Examples are GPs and community nurses. They are generally the first service an older person with a life-limiting illness may go to for health care, outside of a hospital or specialist. [1]
Comprehensive care that is planned and delivered by health professionals across a range of disciplines. These professionals may be from the same or different organisations. They work together to address as many of the older person’s needs as possible. [2]
Multidisciplinary health care services that focus on ongoing care and consultation for people with a life-limiting illness. This also includes supporting their family and carers. In general, specialist palliative care services are not directly involved in the care of people with uncomplicated needs related to a life-limiting illness. [1]
Access to specialist palliative care differs across Australia. The National Palliative Care Services Directory has information on accessing a specialist palliative care service.
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How to work together in residential aged care
The following strategies provide guidance about how to work effectively with older people, their families and carers, and across services and sectors of care.
Improve clinical communication
Clinical conversations and handovers should be clear, focused, and include the relevant information. Involve the older person when practical. The ISBAR is a tool to improve clinical communication and can be customised to specific clinical contexts.
ISBAR (pdf) is a mnemonic standing for:
- Identify/Introduction: Who you are and what is your role?
- Situation: What is going on with the older person?
- Background: What is the clinical background/context?
- Assessment: What do you think the problem is?
- Recommendation/Risks: What actions would you recommend and what are the risks?
Assign and accept responsibility for actions to be taken in a specific timeframe.
Clinical conversations and handovers should be clear, focused, and include the relevant information. Involve the older person when practical. The ISBAR is a tool to improve clinical communication and can be customised to specific clinical contexts.
ISBAR (pdf) is a mnemonic standing for:
- Identify/Introduction: Who you are and what is your role?
- Situation: What is going on with the older person?
- Background: What is the clinical background/context?
- Assessment: What do you think the problem is?
- Recommendation/Risks: What actions would you recommend and what are the risks?
Assign and accept responsibility for actions to be taken in a specific timeframe.
Coordination of quality care at the end of life is driven by:
- Communication that is clear, accurate, timely, and respectful between all team members involved in the care of the older person. This also includes the person’s family and carers.
- Appropriate use of verbal communication, like during a team meeting.
- Proper documented or written forms of communication, such as electronic care records.
- Team members having clear knowledge of who they can share information with, and what information should be recorded and reported.
palliAGED offers more information on care coordination and Practice Tips on Talking within the Aged Care Team for Nurses (pdf) and Careworkers (pdf). There are also Practice Tips on Continuity of Care for Nurses (pdf) and Careworkers (pdf 437kb).
Case conferences are one way to share information among team members. Having everyone ‘on the same page’ regarding care goals is important. This includes all health professionals, the older person, and their family and carers.
In residential aged care, the GP provides medical oversight of the older person. In some organisations, Nurse Practitioners may also be involved in an older person’s care. Convening a palliative care case conference when a person is nearing the end of life will include input where possible from: Medical, nursing, allied health, chaplaincy, and the older person. Family and carers can assist with clarifying goals of care and care planning. Palliative care case conferences may also be repeated on an ‘as needs’ basis.
The following resources offer further guidance about how to facilitate and contribute to case conferences:
- palliAGED has Practice Tips on Case Conferences for Nurses (pdf) and Careworkers (pdf).
palliAGED has forms and templates to assist in planning and holding Palliative Care Case Conferences with older people, their families and carers, and team members. You can type text directly into these documents. This flowsheet explains the process of using these forms, which are listed below.
Planning and Preparing for a Case Conference:
- Information for the Older Person and their Family (pdf)
- Invitation for the Older Person and their Family (pdf)
- Confirmation for the Older Person and their Family (pdf)
- Planning checklist (pdf)
Information for GPs:
Information on how to Conduct a Case Conference:
Palliative Care Needs Rounds (PCNR) [3] identify older people in residential aged care who have specialist palliative care needs.
- The PCNR meetings with the care team are led by a specialist palliative care team member if available, such as a nurse practitioner or clinical nurse consultant. These meetings are typically held monthly where 5-10 individuals’ needs are reviewed.
- Meetings use a case-based education model with discussion of the older person’s physical, psychosocial, and spiritual symptoms. This also includes how to promote holistic symptom management.
- The PCNR meetings are guided by a checklist. The process supports the palliative care skills and knowledge of team members. Meetings inform care and anticipatory planning, which aims to improve the quality of death and dying for the older person, their family and carers.
- See the Palliative Care Needs Rounds: The Implementation Guide for more information (pdf). [3]
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How to build knowledge, confidence and skills in working together in residential aged care
- Gain a better understanding about when to refer to specialist palliative care by listening to the ELDAC podcast on this topic.
- Watch the ELDAC Work Together educational video to help identify the components of multidisciplinary teamwork. The video assists in the understanding of using case conferences to plan care, and offer proactive palliative care to regularly reassess needs.
- Increase your skills and confidence by seeking advice from more experienced colleagues or by closely observing them as they facilitate a case conference or communicate in team meetings.
- Review the ELDAC Case Study on Dorothy to see how the multidisciplinary team work together to achieve high-quality care. Explore the ways different members of the team contribute to addressing Dorothy’s physical, social, psychological and spiritual needs.
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Information for families and carers
Palliative Care Australia
This brochure has information about who palliative care is for; where it is provided; and who is in the palliative care team.
Palliative Care Support for Patients, Carers and Families (4MB pdf)
CareSearch
This booklet provides basic information about palliative care for individuals, families and carers.
Information for you and your family: Palliative care case conferences (pdf)
palliAGED
This resource explains what a palliative care case conference is, and why it can be important.
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References
- Palliative Care Australia. National Palliative Care Standards for Specialist Palliative Care Providers. Canberra (AU): PCA, 2024, 5.1 edition. [cited 4 April 2025].
- Aged Care Quality and Safety Commission. Draft glossary of terms: Guidance material for the strengthened Aged Care Quality Standards for review and discussion. 6 February 2024 [cited 4 April 2025].
- Little Company of Mary Health Care Limited and University of Stirling. Palliative Care Needs Rounds: The Implementation Guide (pdf). Canberra (AU): Calvary Health Care, 2020 [cited 11 June 2025].
Page updated 28 September 2026
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