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Issues In Rendering Palliative Care


Introduction: "Residential aged care facility" is aged care facility being offered to the veterans and this involves supporting the activities every day on daily basis. Often Residential aged care facility term used interchangeable with other words like nursing home, convalescent home as well as long-term care facility. When compared with the past, there is increased adoption of the residential aged care facilities on global basis. In Australia itself about 50% of the total aged people are residing in the residential aged care facilities. Aged people in Australia constitute about 12% of the total population and hence constitute significant number. As of recent statistics, 2017, about 1.4 million people are staying in nursing homes in United States of America and they are being covered by Medicaid. Hence considering the sheer volume and the recent growth rate of the deaths of the people (Pivodic et al.,2016) under the residential health care facilities, the significance of palliative care in the residential health care facilities is emphasized. The following part of the discussion is aimed at critically evaluating the issues related with palliative care of the residential aged care people. More specifically the focus is on the diverse aspects like wellness modeling, user pays, case management etc. Further the critique is performed on the issues form political, philosophical, legal and ethical perspectives. The discussion is also extended to include the strategies related with the palliative health care services delivery models.

Question 1: Explain palliative care provision in residential aged care.

Answer: Palliative care is the special treatment for the people with life limiting illnesses and the focus of the treatment will be just to improve the quality of life of the life of the patient as well as the family members. As a whole, palliative care works on to provide relief of physical, mental and emotional stresses and this in general will consider the psychosocial, physical and mental factors into consideration while offering the treatment (Chan et al., 2016).

Palliative health care delivery is aimed at providing the best quality of health to the people. The end of life care of the people considers the following principles,

• Dying is normal aspect and is inevitable for human beings

• Patients should be provided with the empowerment to judge their own health care facilities

• Working out to meet the cultural, social and spiritual needs of the people is very much essential

• Evaluating the end of life period of consumer and planning the health treatment and the changes in health care accordingly

Inherently the principles of the palliative health care consists in following objectives

• Assessing , documenting and meeting the changed health care requirements of the patients

• Ensuring equitable access to all the patients particularly at the end of life scenario.

• Providing health care services as per the values, believes, religious interests and personal choice.

• All the residential health care facilities need to be equipped with the necessary palliative care provisions

• Staff need to possess the necessary training and resources for the delivery of the health care facilities

• The care is expected to be holistic and seamless, palliative care needs to respect the dignity, privacy of the patients and also there is need for consideration of supporting the families and carers in the bereavement.

• Further consumer role as contributor to be acknowledged and recognized.

On critical evaluation of the aged care needs in the residential care set-ups, it can be said that there is no single framework or model best suitable for all the requirements of the aged people in general. Any model for meeting its objectives of the palliative aged care, it need to be dynamic in accordance with the changing population demands as well it also required to be sensitive and accommodating the cultural, social, psychological, economic as well as the cultural interests of the patients(Frey et al.,2017).

• Trajectory model of the palliative care is very much appropriate for serious and chronic illnesses, normally treatment under this model will start early and will proceed with the meeting the continuous and intermittent needs of the people. It will also enable the people cope up with the illness and bereavement of the patients as well (Jackson et al., 2016).

• Community health care model will enable the patient and family comfort and satisfaction and also will work on to let the patient get the treatment at home.

• In any case an effective palliative care in RACF (Residential Aged care facilities) will be integrative and will work with collaboration and integration of diverse stakeholders.

Question 2: Critically discusses advanced care directives in residential aged care.

Answer: Advanced care directives in the residential aged care will be normally considered and embraced as part of the routine care. They will be discussed and made part of the care, much before the end of life conditions of the patient and the subsequent arrival of the dementia conditions. Broadly speaking they will record the patient's future care preferences and they may include a substitute decision maker for advanced care provisions. Some of the key aspects of the advanced care directives in the residential aged care include the following,

• There should be accessible written policies and procedures about advanced care planning.

• There is need for regular education and training for the GPs and other staff.

• Information about the residential health care need to be provided to the patients and the staff much before the actual admission.

• ACD need to be administered within 28 days of admission

• The directives will be employed after consulting the resident comprehensively or sometimes the relatives of the residents

• Plans implemented will be chronically reviewed and modified

• SDN need to be nominated and availed as per the needs

• There is need for effective communication and the entire advanced health care directives need to be informed across the organization for other health care service providers.

• Advanced health care directives are the instructions of the care by the patient in advance, the type of care setting patients wanted for their care requirements will be provided in advance and they will be considered in rendering the palliative care to the patients. In the cases when and where needed, a subsitutional palliative health care provider also will be provided.

• Advance care directives will consolidate the final health care requirements of the patient in accordance with the characteristics like values, life goals, cultural, linguistic, spiritual and religious preferences of the people. The psych-social, emotional and cultural values and religious preferences etc become the guiding factors in formulating the set of ACD for any patient.

• Out of the options available the ACD provisions with the best health care practices that are in coherence with the value systems of the patients will be selected and they will be aligned to make sure that the patient will be availed of the most appropriate and effective health care possible through these channels(Jeong et al.,2011).


Legal and Ethical issues in advanced care planning: Legal and ethical framework is mandatory in enforcing an operational framework for Advanced care directives in general. This is very much essential to ensure advanced care directives are following stipulated operational objectives. The most important of the legal issues guiding the advanced care planning are as follows,

Advanced care planning is both legal as per the statute legislation as well as per the common law in the countries like Australia. However other supporting aspects like written documentation of the advanced care planning, compliance of the same with the current condition as well as the recent care plan makes it stronger. Further evidence that the advanced care plan is prepared without any unduly influence as well as with perfect condition will provide substantial support to the care plan allegations. Ethical concerns in preparing and execution of the strategy consists in giving weightage and relevance to the advanced care planning by providing an ethical opportunity to the patient to get into a particular framework to include his interests and personal care preferences. The key ethical concerns also include honoring the opinions of the patient as well as their cultural, religional and emotional concerns.

Question 3: Considers strategies that may improve the provision of palliative care in residential aged care.

Answer: Legal framework of advanced health care Planning: The key framework of advanced health care facilities includes, legal rights of the patient to choose a health care service plan in accordance with their interests. Further the underlying legal principle in legitimizing the statute is contained in the fact that everyone has right to opt for a particular advanced health care planning. They have legal right either to opt for a particular advanced health care planning, refute or ask for modification of a particular advanced health care service as well.

In future if the patient has lost his senses and if is not in a position to take up the decision, his previously proposed or drafted advanced health care plan will be legally enforceable. Further as an alternative a legally appointed decision maker can support the person to take up the decisions regarding the advanced health care. Also it is possible that a substitute decision maker may be appointed by the patient and his suggestions will be considered for finalizing the advanced care planning. Each of these modes and procedures are legally protected and they are enforceable. Further the advanced care planning can be protected when the person is moving from one region to another region within a country. The state laws will respect the advanced care planning of the patient irrespective of the location where he is residing.

However it is much easier to offer legal protection and enforcement of the advanced care planning when it is in accordance with the previous recent planning adopted, when it is in alignment with the actual needs of the treatment, also if they are previously expressed by the patient and written evidence existing for it. If they are matching the treatment requirements and if there is proper wording for the same and if there is signature and validity of the facts that it is presented in fully presence of conscious and without any unduly influence. Wording of the advanced care plan also matters, if it is provided without any confusion and without any vague wording, it can be legally valid and stronger to enforce. However competency of the patient is a key criterion that postulates and supports the applicability and validation of the Advanced care planning in general (Stewart et al., 2011).

Normally the legal requirement in most of the cases is getting the signature of two or more witnesses along with the patient on the formal health direction. Further there is legally possible chance for the patient to revoke or withdraw the health plan by signing the same. Further it is also possible for the physician to execute the health care plan only when he is assured and confident that the direction is genuine made by the patient in due presence of mind as well it is also in the legally acceptable format and competent. Even in the mental health care conditions also the patient is allowed to make up advanced agreement seeking certain type of the end of life health care or modifying the existing models of the health care. Also it is possible for them to either refute or withdraw the health direction legally(Jeong et al.,2010).

Ethical framework of advanced health care plan: Health direction is contained in its basic consideration to the ethical aspects. It is believed that it is ethical obligation for health care service providers to provide the services in accordance with the interests of the patient. It is ethical and moral right of the patient either to change the health care plan or to modify the existing one(Ulirch et al.,2010). Further the patient will also possess right to deny the treatment, if he feels that it is not as per his value systems. Considering all these aspects is also an obligation on part of the government to ensure the advanced care directives to be as per the interests of the patient. A patient has right to even seek the assistance of a substitution decision maker to help him in taking up the decisions to ensure his advanced health care plan get executed, when he is not in a position to propose the same(John,2018).

Advanced health care planning is a voluntary process and it is quite ethical aspect that the patient needs to be provided with the necessary freedom to choose the type of the health care plan in the later stages when his condition will not be facilitating him to take up the decision. Also in the circumstances when the patient conditions will further detoriate also, it is difficult for the person to request for the health care plan that he need for, in all such circumstances it is a viable and ethical option for the person to propose a means to set his health care plan(Mullick et al.,2013).

Afterall it is a birth right of a person about options like where he want to die? Where he want to get treatment for his terminal treatment, the type of treatment procedures he want to opt for and the ones that he did not. These recommendations can be in line with the interests of physical, spiritual and religious interests of the patient and hence the health care planning process can work on ensure the patient will get the right treatment as per his interests. It is ethical requirement to get these things happened (Ley, 2018).

Apart from discussion on these basic aspects of the ethical framework for advanced health care planning, it is also very much required and beneficial too. People can able to exercise certain type of control over their lives through advanced health care planning. However it cannot be ignored of the possible pitfalls in the system. When it is not drafted comprehensively, it is much likely that the advanced health care plan will not meet its requirements positively. If there is no consideration made to the uncertainties and possible eventualities which are not foreseen, there is considerable chance that the health care plan direction made now, may be not of use or may need totally a different strategy.


Strategies that may improve palliative health care provision in the residential aged care:

Possible issues with the advanced care planning in RACF:

Advanced care planning consisting of consideration to the values, norms and beliefs of the people and application of the same to drafting the advanced care planning for the personnel(Thomas et al.,2017). More specifically it is related with the designing an optimized advanced care planning for patient care and as per the preferences of the patient. Often variety of issues do surface and remain as an obstruction in implementing these care plans,

1. Most commonly the strategies will include drafting the medical directions that are uninformed and too specific for accounting the changes in the care plan and treatment and sometimes they will be very non-specific to work out any decision to make an appropriate decision planning. Either way it is detrimental to the optimized and appropriate advanced care planning in the organization(Jeong et al.,2011).

2. Substitute decision makers for advanced health care planning are found to be very much uninformed of their functionalities and often they do not contribute to the actual decision making process. Their role remains non production and non-contributing to the advanced care planning for the patient(Jeong et al.,2011).

3. People do change their preference in the course of time, the procedures and values which they have adopted some in their life will become change and they don't update the same in the drafting of the advanced health care planning. Hence the implications of the same will become often constrained.(Olivier & Hargreaves,2017)

4. Another important issue is that the physicians who are responsible for the implementation of the advanced health care plans ignore the directive of the patient as well the directives of the SDM and prepare strategies without including the recommendations of the same and hence will not justify the cause of the creation of the advanced health care planning itself.

Possible solutions: • Improving the knowledge of the health care service providers by variety of strategies can contribute to the improvement of the palliative health care in the residential aged care facilities. 

• Specifically when it is required to improving the systems, special focus to be made towards the delivery system of PC. There is need to include sufficient number of delivery channels and appropriate models in rending palliative health care.

• Further there is need to include sufficient number of workforce members in the palliative health care.

• Ensure the availability of the resources as per the requirements. Further developing ethical compliance in the model and ensuring the compliance of the same.

• There is need to procure and employ evidence based data and subsequent evaluation and application of the findings in the palliative care improvement makes up very important part of the strategy in promoting the same in the residential aged care facilities.

• For improving the efficiency (Silvester et al., 2013) and for optimizing the palliative care facility a comprehensive interweaving of diverse stakeholders and working with interactive brainstorming operations, processing mapping and investigation of the improvements, working out more rigid controls, designs, proper control and binding are necessary for the same of improving the palliative care facility operational efficiency.

• This is very much significant that the palliative care need to focus on the improvement of the quality of the life of the patients in the health care settings particularly who are in the life limiting illnesses. Quality of life to be improved both for the patient as well for their family members too.

• The procedures and strategies of the palliative care are focused on offering the relief to the patient in terms of providing them relief of stress from physical, mental, psycho-emotional stresses. These stresses are inhibitors from availing better health care and the focus of the attention need to be here on these aspects of the health care improvement.

• Residential health care setting or the houses of the veterans normally will need palliative care more intensely than in other forms like in the acute health care setting. The typical strategies in these settings include training the health care providers and the supporting staff with the procedures, tools and the equipment of the palliative care. The models and the procedures will be developed to include palliative health care and for improving the quality of the health care in general(Street et al ,2015).

• There is need for continuous updating of the quality of the health care services. In this regard continuous auditing of the quality of the health care services (Palliative care) to be performed by employing right stakeholders in the system. An insight into the operational efficiency of these care measures will impact the overall quality and performance of the health care services. Benchmarking the quality of the palliative care with the prevailing health care measures. Working for the betterment of the health care services in accordance in the legal and ethical regulations, policies and prevailing government decrees to be ensured.


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