- Short period of evident decline – these residents may have good function for a long period followed by a few weeks or months of rapid decline prior to death.
- Long-term limitations with intermittent serious episodes – these residents will have gradual decline in function. During each acute episode, the resident is at risk of dying but they may not. However, function will continue to decline.
- Prolonged dwindling – the resident has a long-term progressive disability and reduction in function. Death may be caused by infections, falls or fractures.
Across all these illness trajectories, it is important to identify and respond appropriately to deterioration of the resident caused by their primary diagnosis or as a result of other disease or events. However, it is important to distinguish between deterioration that is due to untreatable causes, such as disease progression or an acute or medical emergency that may warrant review and treatment. Good clinical assessment and consultation with the resident’s GP, and if needed, external experts such as specialist palliative care is critical. The family should be contacted regarding the person’s deteriorating condition.
palliAGED has downloadable Practice Tips on recognising to deterioration for Nurses (pdf 276kb) and Careworkers (pdf 349kb).
Continuity of Care
To ensure appropriate care is provided after hours, your organisation should have access to after hours medical care and this should support continuity of care. In some states and territories the acute hospital services have rapid response teams that may be able to offer phone support or provide a consultation. Similarly, in some states and territories extended care paramedics might be available. It is important to know your local options well in advance of the person requiring emergency review. This may be something that could be addressed as a quality improvement activity, which is discussed in the organisational section of this toolkit.
The resident’s wishes expressed in an advance care plan or advance directive should also guide decisions. In the event that an emergency department presentation and/or hospital admission is required, clinical information should accompany the resident. This includes legal documents identifying substitute decision makers, advance care plans or an advance care directive. Liaison with the hospital following transfer may facilitate the resident’s return if their condition stabilises (dependent on resident’s wishes). If you are able to provide the care required for the resident you should discuss this with the hospital staff.
palliAGED has downloadable Practice Tips on continuity of care for Nurses (pdf 369kb) and Careworkers (pdf 449kb).
Supportive and Palliative Care Indicators Tools (SPICTTM)
The SPICTTM and user guidelines are free to download, but the developers of the tool ask that you provide your details prior to download so they can keep you informed of SPICTTM updates and relevant SPICT news.
Use of the Supportive and Palliative Care Indicators Tools (SPICTTM) for all residents during routine care evaluations and following an unplanned hospitalisation may indicate a change in the resident’s condition that warrants a review of care needs.