Despite considerable evidence that care in residential settings for older people is sub-optimal, designing, implementing and then ensuring wide uptake of evidence-based approaches is in its infancy.  Key priorities of reducing avoidable admissions and decreasing length of stay involve improving staff knowledge and capacity to recognise deterioration and dying, manage symptoms, and having adequate planning and prescribing for end of life. Substandard care has been the focus of a Royal Commission into Aged Care Quality and Safety in Australia.

Aim

To describe the process of designing, testing and disseminating a new intervention called Palliative Care Needs Rounds (PCNR) in Australian care homes.

A stepped wedge, mixed-method randomised controlled trial with 1700 care home residents in Canberra, Australia. 

Having completed the definitive trial, we engaged in a sequence of dissemination events to distribute research outcomes and facilitate uptake of evidence-based practice to other palliative care services, nurses, healthcare professionals and key stakeholders.

PCNR identified residents most at risk of dying without an adequate plan in place. The study reduced avoidable hospital transfers and length of stay saving a conservative AUD $1,700,000 per year; improved staff confidence and knowledge; and showed that participants were more likely to experience a better quality death. 

Impact was achieved through varied routes of influence, including dissemination of research results through peer-reviewed publications and conference presentations, submitting and giving evidence to the Royal Commission, directly contacting Health Ministers and holding meetings with senior public servants, writing letters to Local and Commonwealth Government Ministers, and building relationships with departmental budget officers. Using implementation science we developed a suite of resources freely available nationally and internationally to implement PCNR and have a positive impact on care for older people.  

The PCNR model and our meetings with key stakeholders and Government were instrumental in informing the development of the Australian Government’s investment into specialist palliative care services of AUD $32.8m over four years from 2018-19 for the Comprehensive Palliative Care in Aged Care measure. 

The ACT Government allocated funding of $1.6m AUD to Calvary Specialist Palliative Aged Care Service to implement PCNR in all residential care homes across the Territory.

Broad dissemination of research findings and using implementation science to develop resources facilitates uptake of evidence-based practice, can influence health policy and funding decisions and have an impact on improving nursing care. 

With an ageing population and a greater proportion of dying happening in hospital, the provision of quality end of life care (EOLC) is essential. However, there is a relative lack of data on Australian practices with regards to the quality of communication, documentation, and provision of EOLC in the geriatric ward setting.

To describe end of life care provided to dying patients in the geriatric ward setting at a large tertiary hospital in Melbourne, Australia.

 

A retrospective cohort study was performed in patients who died in the Geriatric Medicine ward at a tertiary public hospital between January 1st 2013 and December 31st 2018. 

 

Of the 157 patients audited, 55.4% were male with a mean age of 86.0 years and Charlson comorbidity score of 2.2. The median duration of their final admission under the geriatric team was 17 days IQR [9,27]. 

Goals of care discussions were initially documented a median of 9 days prior to death IQR [4,17]. Three percent of patients had a pre-existing advance care directive and 14% had a Medical Treatment Decision Maker. 

Identification of dying was documented on median 3 days prior to death IQR [1,7]. Almost all patients (92.4%) had medications rationalised whilst 47.8% were reviewed by specialist palliative care and 56.1% placed on an EOLC plan. 

 

Conclusion:
This study illustrates the importance of early discussions with patients and family as well as highlights the role of advance care directives and medical treatment decision makers in aiding shared decision-making. Further opportunities with education for clinicians on recognising and responding to dying earlier as well as discussions regarding goals of care could improve the quality of end of life care for geriatric patients. 

Advance care planning (ACP) conversations may result in preferences for future medical care being documented and made available at the point of care. The goal of ACP is that people receive preference aligned care. The availability of ACP documentation, including advance care directives (ACDs) created by the person and non-ACDs created on behalf of the person by a health professional (e.g. Goals of Care or medical order) or someone else (e.g. advance care plan, statement of choices no capacity), is an important indicator for quality palliative care.   

The Prevalence of ACP documentation in Australian Health and Residential Aged Care Services study aimed to explore the uptake and quality of ACDs among older Australians accessing health and aged care services, by overall ACP documentation prevalence and ACD quality indicators. Secondly, to describe the organisational-level predictors of ACD prevalence. 

National multi-centre health record audit in general practices (n=15), hospitals (n=27), and residential aged care facilities (RACFs; n=58). 

This study suggests that there is limited documented planning for future medical treatment decision-making, and the development and storage of a person-completed ACD is not routinely part of care in Australia. Overall ACP documentation prevalence was 29% (weighted) and ACD prevalence was 14% (weighted). Unweighted ACD prevalence was higher in RACFs (38%) than hospitals (10%) and GPs (6%). 10% of ACP documentation was completed by a health professional and 11% by someone else. Only 73% of ACDs included full name, signature, document date and witnessing which may limit clinical application. 

Most organisations reported having an ACP program, ACP training for staff, ACP resources and ACD templates for patients/residents, and mechanisms to record the presence of ACD(s). However, only the time since ACP program implementation influenced ACD prevalence. Metropolitan sites and privately funded sites, showed lower prevalence rates in an adjusted model. 

Delirium is a common medical complication, especially in patients with older age and serious illness. Long-term custom has been to administer antipsychotics for delirium; however, recent studies cast doubt on this practice.

To investigate the influence of these recent studies and other factors on clinicians’ delirium treatment practice and practice change in palliative care and other specialties using the Theoretical Domains Framework (TDF).  

Australia-wide online survey of registered nurses, doctors, nurse practitioners and pharmacists who cared for patients with delirium in diverse settings. Discipline-specific surveys were piloted before recruitment via 15 health professional organisations in 2019. Outcomes (practice change, current practice, and influences, including four named studies of antipsychotics for delirium) were determined for the overall sample, and for palliative care versus other respondents, using descriptive statistics and Pearson’s Chi-squared Test.

Most of the sample (n=475) worked in geriatrics/aged (31%) or palliative care (30%); in hospitals (64%); and saw a new patient with delirium at least weekly (61%). More (59%) reported delirium practice change since 2016, mostly by increased non-pharmacological interventions (53%). More (55%) reported current antipsychotic use for delirium, primarily for patient distress (79%) and unsafe behaviour (67%). Common TDF influences on delirium practice were emotion (54%); knowledge (53%); and physical (43%) and social (21%) opportunities. Palliative care respondents more often reported: awareness of any named study (73% vs 39%, p<0.001); changed delirium treatment (73% vs 53%, p=0.017); decreased pharmacological intervention (60% vs 15%, p<0.001); off-label medication use (86% vs 51%, p<0.001: antipsychotics 79% vs 44%, p<0.001; benzodiazepines 61% vs 26%, p<0.001); and emotional influences (82% vs 39%, p<0.001). 

We conclude that clinicians’ use of antipsychotic during delirium remains common and is primarily motivated by distress and safety concerns for the patient and others nearby. Supporting clinicians to achieve evidence-based delirium treatment requires ongoing attention.

Background:
Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement.

Aim:
To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions.

Design:
Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data sources:
We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews, and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised, and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions.

Results:
From 13/3244 studies (2863 adult participants), we identified nine delirium-specific and 13 non-delirium specific and outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n=7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium outcomes included mortality, agitation, adverse events, other symptoms, and quality of life.

Conclusion:
The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.

Background
Palliative care for people dying of dementia and their carer/s is a growing area of need. A tool to identify the needs of this person-carer dyad is a necessary component for providing this care. The aim of this project was to determine the validity of a new tool, the CArer directed NeeDs assessment In Dementia (CANDID), which was developed for use in a randomised trial of palliative dementia care.

Methods 
Face validity of CANDID was assessed by an expert panel. To assess criterion validity, a narrative review of the literature to evaluate existing tools available for assessing the needs of carers of people with advanced stage dementia was conducted. A sample of ten trial participants independently completed CANDID and the Carer Specific Needs Assessment Tool (CSNAT), which was identified as the best existing tool from that narrative review. Participants also completed an evaluation survey to determine which tool they preferred, and why.

CANDID has face validity. There were insufficient participant numbers to establish criterion validity

Conclusions 
Participant carers of people dying of dementia in this trial setting preferred a face to face evaluation of needs. Further study is required to confirm the utility of CANDID however preliminary results from this study suggest that it is a valid tool. 

Background: 
The full role and impact of palliative care in residential aged care (RAC) is unknown.  This is despite the high level of need for palliative care in residential aged care (RAC) in Australia and the substantial number of people that die in RAC every year (≈60,000 people each year). The Palliative Care Outcomes Collaboration (PCOC) is a national outcomes and benchmarking programme that leads to statistically and clinically significant patient outcomes, through a systematic and standardised assessment and response process. Its full potential in RAC is emerging.

Aim: 
To determine how the PCOC model needs to be modified for RAC

Methods: 
Exploratory applied investigation with real-world applications analysed  

Results:
The adaptation resulted in the 5 validated PCOC assessment tools being recommended for use in RAC. However, a modified Assessment & Response Protocol was found to be essential, with care workers to complete daily assessments of symptom distress under the supervision of nursing staff.  An escalation and screening protocol was also required to ensure adequate palliative care, supporting good practice and the identification of appropriate & timely referral to the specialist palliative care services when required.

Conclusions:
In RAC where the resident to nurse ratio is vastly different to other palliative care settings, the involvement of care staff to identify and escalate clinical need informed by validated outcome measures is possible. Benefits include a communication tool for care staff to advocate for residents in distress. A common language to communicate and refer to specialist palliative care providers, improved timely access to palliative care for residents and better joined-up care for older Australians may result. 

Funding Acknowledgement:
This project is a collaboration between PCOC, the Australian Health Services Research Institute and Aged Care Providers, and is supported by funding from the Wicking Trust and the Australian Government Department of Health.

Background:  
The Palliative Care Outcomes Collaboration (PCOC) delivers a successful national program in palliative care to improve patient and carer outcomes. The PCOC Wicking Model was developed to address the unique needs of people in residential aged care (RAC) settings. The Model involves:

Our aim is to describe key findings of the evaluation of the PCOC Wicking pilot, including the outcomes of education and enablers to implementation.

Methods: 
PCOC provided the resources needed by participating RACFs (n=7) to implement the PCOC Wicking Model which included face to face education for RACF staff and continuing support. The evaluation included surveys of RAC staff confidence in providing palliative care (n=307) pre and post-education, and semi-structured interviews with 35 RAC and PCOC staff to explore experiences of implementing the Model. Thematic analysis was undertaken. 

Results:  
The majority of RAC staff reported moderate levels of confidence in most aspects of palliative care pre-education. Confidence increased further post-education (Careworkers’ mean total confidence score pre-education:28/40 vs 30/40 post-education; Health professionals’ mean pre-education score: 30/40 vs 34/40 post-education). 

Key enablers identified in the interviews included: preparation and readiness, a receptive context for change; availability of resources; multi-modal and ongoing education and training; and fit with everyday practices and systems.

Conclusion: 
To successfully implement the PCOC Wicking Model, RAC services must be well engaged, prepared and have a clear understanding of the processes and resources required. While education improved the confidence of RAC staff to effectively deliver palliative care, some staff identified the need for ongoing support and training to embed the Model into routine practice.