Transition to end-of-life in the aged care setting: Identifying the changes

The purpose of this research study was to identify the perceptions of aged care health care personnel (ACHCP) working in residential aged care facilities (RACFs) of the changes that indicate a resident has entered the end-of-life (EOL) phase. This is a challenging time for ACHCP because the changes in the resident's condition are frequently subtle and sometimes difficult to identify due to their slow deterioration, often over many months. In order for the best EOL care to be given to residents, timely and accurate assessment of this phase would enable the best possible and most appropriate care to be commenced. This study utilised a mixed methods methodology and was conducted in two phases. Phase 1 employed a qualitative approach using interviews underpinned by the interpretive paradigm to enable ACHCP to describe the changes that occur when a person being cared for in a RACF enters the final stage of life. In phase 2, the Delphi consensus method was used to confirm two themes that were found in phase 1. A reflective journal was kept throughout the research study by the research student. The phase 1 findings revealed two themes which provide a rich description of the culture of ACHCP and are described in the domain: Culture and Context. Other themes which emerged described two distinct phases that occur sequentially when a resident is close to EOL. The early phase occurs around two weeks before the second or later phase which occurs around one to three days prior to death. Both the early and later phases encompass the EOL phase of care. In each of these phases there are distinct changes that present in relation to the resident's physical status and their engagement with their surroundings. Several of these changes were regarded as clusters and it was felt that for them to be used reliably as indicators of transition to the EOL phase, it was necessary for all to be present.;Another theme, They Get a Certain Look About Them is related to the early and later phases of EOL, and collectively, these themes comprise the second domain: End-of-Life. The Delphi method was selected for phase 2 of this research study in which consensus was sought from an expert panel of ACHCP regarding the two EOL phases described in phase 1. A series of statements was developed and offered to the panel of experts in the form of an online survey tool. The level of consensus was set at 75%. Participants agreed that there are two distinct phases which signify to them that a resident being cared for in a high level RACF has entered the EOL phase. There was consensus agreement that there is an early phase around two weeks before a later phase which occurs two to three days before death. The signs associated with the early phase were decreased appetite, increasing frailty and becoming more withdrawn. The signs associated with the later phase were changes to the skin, breathing changes and changes to the circulation. The participants agreed that all of these signs and indicators should be present to confirm the EOL phase. The findings of this research study have confirmed knowledge from previous research and reinforced the relevance of identification of these two stages for nursing practice in the aged care setting. Specifically, it has confirmed an early phase of change associated with the early signs of EOL. Further, it has refined the traditional signs of the later phase used in other care settings and reinforced signs which are specific to this group, elderly people being cared for in high level RACFs.;A reassessment of the current management of the resident and commencement of the most appropriate care based on the early identification of the early phase, around two weeks before the later phase, would enable ACHCP, medical practitioners and family members to initiate interventions that would provide the basis for the most appropriate care at the EOL. The implications for nursing practice are that a more specific set of signs and indicators which may determine the EOL phase of care for residents being cared for in RACFs. As a way of making this information available to ACHCP, it could be incorporated into educational programmes and resource material currently available to them, the aim being to promote the best and most appropriate care for residents at the EOL. The recommendations for future research are to establish the sensitivity of the signs and indicators to determine the early and the later phases and to develop and refine an assessment tool which may be used by ACHCP to confirm the commencement of the EOL phase.