Respond to Deterioration
Clients will experience different illness trajectories depending on the primary diagnosis and presence of other diseases (comorbidities).
Palliative Care Australia identifies that there are three common trajectories of illness for people with a life-limiting illness (PCA 2018 Palliative Care Service Development Guidelines):
- short period of evident decline – these clients 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 clients will have gradual decline in function. During each acute episode, the client is at risk of dying but they may not. However, function will continue to decline.
- prolonged dwindling – the client 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 client 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 client’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 'What My Organisation Can Do' section of this toolkit.
The client’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 client. 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 client’s return if their condition stabilises (dependent on client’s wishes). If you are able to provide the care required for the client 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).
ELDAC Toolkit Educational Video
Watch the Home Care Toolkit educational video on Manage Dying, which also discusses how to respond to a client that is declining in health.
Supportive and Palliative Care Indicators Tools (SPICTTM)
The SPICTTM and the 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 clients during routine care evaluations and following an unplanned hospitalisation may indicate a change in the client's condition that warrants a review of care needs.
Another version is available called the SPICT-4ALLTM, which has easy to understand language and is designed to be used by everyone – people with long term illnesses, family and healthcare staff. The SPICT-4ALLTM makes it easier to identify and discuss the signs that a person’s overall health may be declining in order that they receive the care they need in a timely manner.