- 27 May 2020
- Duration: 52:28 minutes
JESSICA SIMIONATO:
Good afternoon, everyone. My name is Jessica Simionato and I am the Senior Project Officer in the Centre of Clinical Excellence of Older People, at Safer Care Victoria. On behalf of the Department of Health and Human Services, a very warm welcome to everyone online, and thank you very much for joining in today's webinar for Victorian residential aged care services titled, Palliative Care Within Residential Aged Care During the COVID-19 Pandemic'. Before we begin today, I'd like to start by acknowledging the traditional owners of the many lands in which we're meeting and pay my respects to their Elders past and present, and the Aboriginal Elders who may be joining us today. Before we start, there are a couple of housekeeping things to cover. Not all the presenters represent Safer Care Victoria or the Department of Health and Human Services. The views expressed in this webinar are that of the presenters whom we thank for their generous time today in sharing their knowledge and expertise. We expect the webinar to run for around 60 minutes, including some dedicated time for Q and A at the end.
You may ask questions of the presenters throughout the webinar via the chat box, and we'll do our best to respond to these during the webinar. Our webinar will be presented as a panel presentation today and we'll direct those questions directly for people as we go. And finally, if you're experiencing any technical issues, please feel free to contact Redback helpdesk or type your problem into the chat box. So our panel of experts for today. So we have Penny Cotton joining us. Doctor Penny Cotton is a palliative care physician with the Grampians Regional Palliative Care Team and Ballarat Health Services. Penny is also the Deputy Director of Medical Student Education for the University of Melbourne Rural Clinical School. And welcome, Penny. Jane Newbound is the Aged Care Project Manager at the Southern Metropolitan Region Palliative Care Consortium. Thank you, Jane for joining us. Jane has been a registered nurse for 36 years and in the last 20 years has focused on working in the aged care sector. So, an experienced voice for us today. Erika Fisher is also joining us, and she is the Palliative Care Nurse Consultant and Manager at Western District Health Services. She's a registered nurse in general community psychiatry and midwifery. And she has 30 years experience as a nurse in a vast range of specialist services across three countries. And finally, Steven Peterson is joining us today as well. And Steven is a Consumer Representative for Safer Victoria and will today share his experiences from the perspective of volunteering in aged care services. So thank you, Steven. Before we kick off into our panel discussion, we, as we have done in many of these webinars to date, I wanted to give you a update on the current Coronavirus situation. This brief update comes from the Chief Health Officer's Update and I am provided via email daily, of which all of you can register to receive. And we would encourage you to do so. So, my apologies, disappeared from in front of me. Excuse me, one moment.
So, as of 27 May, 2020, the total number of Coronavirus cases in Victoria is 1,618. This is a net increase of 8% to previous report on 26 May. We had two new cases linked to the Lynden Aged Care outbreak and some others are still under investigation. There are 183 cases that have been acquired in Victoria where the source of infection is unknown, and that is an increase of one since the prior report. We have eight people in hospitals, three in intensive care, and 19 deaths, sadly. There have been 183 confirmed cases in healthcare workers and for this report, that's an increase of one. Happily, there's been 470,000 test results received by the department since 1 January this year. And that's the increase of over 33,000 since the day before this report. So, some good testing numbers still occurring. If people would like for more information, of course, there's updates daily and also, the Department of Health and Human Services dedicated Coronavirus webpage. So, apologies. OK. Excuse me while I just get through here.
OK! So, onto our panel discussion today. So, palliative care, just to set the scene is the active, holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially, of those near the end of life. It aims to improve the quality of life for patients, their families, and their caregivers. And this week, for those of you who don't know, it's in fact, National Palliative Care Week, with the theme, More than you think. So we're really pleased to bring you this webinar topic today and celebrate that it is Palliative Care Week, and the opportunity to share knowledge about the role of palliative care and particularly that in aged care context. To work through today's questions, we are also going to read a quick case study, and just to put things into context for you as we speak today. So, Jack is an 82-year-old retired builder living in your residential aged care facility. Jack has Alzheimer's dementia, prostate cancer, and a history of cardiac disease.
He is usually ambulant with a four-wheel frame. He often does lapses a hallway during the day or finds a chair in the sun room looking out at the garden. He needs regular prompting and reorientating, but still answers simple questions when he's asked. He has urinary incontinence but he manages that with continence aid. Staff have noticed a change in Jack over the past few months. He comes out of his room less, he is not mobilising as well, and he is needing a little bit more help to transfer and shower. They've also noticed that he's lost five kilos of weight in the past three months. And he previously would make his own way to the dining room for meals, but now he's requiring supervision to do that. In the past few days, he seems less interested in eating. He spends more time in bed or in his chair in his room. He will acknowledge staff when they speak to him, but engages less in conversation than previously. And so, as we heard in that case study, the staff have noticed some changes in Jack. And I'm gonna direct this first question over to you, Penny. So from a medical point of view, what are the key things that might indicate deterioration? And also, we're interested to hear what considerations there are in this current circumstance, in the COVID-19 pandemic? Or if you've, we're worried a resident has COVID or because of the impact on the health system, if they needed care for another reason? So over to you, Penny.
PENNY COTTON:
Hello. I guess, as many of the participants would know, that it's often the subtle changes in our residents that indicates some are deteriorating. And it's picking up these subtle changes...
(AUDIO DISTORTS)
...facility where you've got a visiting shift, so you've got lots of different staff, lots of people coming and going. And I think, particularly, at the moment where family (AUDIO DISTORTS)
present in our facility, then I think, we've lost their eyes and ears, and even on our palliative care ward, I feel that raise of burden of, what they're trusting us to be their eyes and ears, and to pick up those subtle changes and to think about those things. And so, I think, that is a significant change at the moment where we don't have those extra sets of eyes who know that patient well, who could tell that something is not right. And so, I think, it's about trusting the staff who know the residents, who have that feeling that something has changed, something is not right. And it could be subtle. And even talking our own gut instincts that Jack's not who he'd normally was. So things like he's engaging less, he's not coming out of his room that much, he's spending more time resting, losing weight which is, I guess, a lot of our residents, residents who have poor prognostic signs, is losing appetite, less mobile, all of those subtle things, project they're quite obvious. But over, you know, busy shift for over a week or two weeks, or three weeks, they're often harder to be, and I think we're finding that as families return to facilities now, that sometimes they're noticing quite significant changes and they can be quite distressed about that, I think that's been the challenge as the restrictions has eased. And I think, it's a challenge that is ongoing to make sure that we are thinking about those subtle changes, including the fact with the senior residents, thinking about, well, what were they doing a week ago? What were they doing a month ago? And what are they doing now? And then, we (AUDIO DISTORTS)
JOYCE:
Sorry, Penny. We've kind of lost you, your audio there. So I'm just gonna bring us back to Jess.
JESSICA SIMIONATO:
Thank you. Great. Sorry, Penny. We did lose your audio there for a brief moment. But I think, you were certainly summarising that those subtle changes that we might see in our residents over time can be missed when we are in a busy shift and particularly, recently, when we've lost the eyes and ears of our friends and family visiting, and so, a benefit of having some lightening of the restrictions is to have, have those extra eyes and ears, and to be aware of the subtle changes in our residents. While we get Penny sort of repair audio... Oh, you're back! This is fantastic! (LAUGHS)
Was there anything else you wanted to add there, Penny?
PENNY COTTON:
So I guess that we're thinking about subtle changes in our residents, we do have to ask that question, could it be COVID? And we do have to think about that 'cause it can present very subtly in our residents. And even right now, at lower rates of community transmission, we do still have to ask that question and go through the process as well, being and know all of the things that that comes with. But I guess, it's just so important from a public health point of view and protecting the rest of our residents to go through that process. And that as that other challenge then of when you've got a resident who's deteriorating and now they're being swabbed, and now the family can't come in and how do we manage that as a community and as a service? Or could it be that he's depressed? Because if the family visiting or could it be that his other underlying medical condition is deteriorating?
JESSICA SIMIONATO:
Great! Thanks, Penny. And so, Erika, you are a palliative care nurse. And I'm interested to hear if you could talk us through the support the palliative care service might provide and in this situation? And if you've had to alter the way you've delivered care because of COVID-19? Yeah, over to you.
ERIKA FISHER:
Thank you, Jess, for inviting me. So in the Western District, there are eight residential aged care facilities in our catchment area, and palliative care plays an integral part of the COVID response. So, as a palliative care team, our response was to draft the pandemic plan for aged care. So what does the pandemic plan look like? We have divided it into four S's under stuff, staff, space, and systems. And that's how we set out education as well. So what does that look like under stuff? So we looked at aged care and looked at what are the things that they really need to be COVID ready. So we looked at the equipment and we found that we are really in shortage of things like syringe drivers, oxygen concentrators and all to do with your symptom management. We've identified that the palliative care drugs in aged care, there has been a ... Not every aged care facility has full access to the palliative care drugs. So we looked at and we compiled a emergency drug kit for palliative care within aged care. So all those facilities under district health now has palliative care emergency drug kits. And also consumables, if we need to have syringe drivers and (INAUDIBLE) in place, we developed a 'grab and go pack', which is easy to use when you're in full gown and you pick it up, you use and you discard. Next thing is staff. We have to look at support for those aged care staff. Because in the region, those staff they know their residents. And they sort it with the residents in restrictions of visitors. So we look through, support through education. We did a series of COVID's in the palliative area. And aged care, the aged care approach patients that we did with the aged care staff. There was a series of upskilling workshops that was run and it included (CROSSTALK)
these questions on syringe driver management. We look at space. Currently, we've got one funded palliative care bed and we have to look at how to maximise that space. So we have negotiated with aged care that we, actually, have more than one bed in there for a non-COVID patient to make sure that if there's an outbreak in the hospital that they don't go directly into a queue. So that would be direct admission to the palliative care bed, in the adjacent aged care facility. And then also systems, which identified key people in aged care to really zoom into updated advance care plans and goals of care for all the residents in there.
It's still in process and a lot of work has been done by aged care. And also look at the care to answer the dying patient. Outcome from all of that, we now have a supportive palliative care symptom management for the non-ventilated, COVID-19 patients. We've got that in draft form now. We have changed the policy on visitation to include residential aged care during COVID-19 crisis. So we have input in that with the patient policy. We now have consumer service offices in all our aged care facilities, to assist and facilitate the change or adapting visiting to aged care residents. Because our rule is if they are palliative or there's a change in their condition, they are allowed apparently to have visitors. There has been refurbishing standards of facilities to accommodate visiting rooms, and it looks fabulous by the way. And also we had through the COVID funding additional devices for communication has been purchased including iPads, speakers and phones and also integrated Wi-fi into television. So the type of message here is and it was important for aged care staff to know this is that all residents in a crisis of COVID will be cared for. What that looks like will differ and any, you know, all aspects is care, whether that is invasive ventilation, or ward-based treatment, or symptom management and end of life care, it all is...that's all key. Have we altered our care to aged care residents? We certainly took the opportunity to look broader and we now have health direct, a telehealth speaker for palliative care, so we can support those aged care staff better, which is really a big thing for us in the region. We have improved our resident communication and take up resident care plans for aged care staff, where we assist the patient and then they can continue with that key plans for the residents. And... We have... We have maintained our consultant as well within aged care. We haven't changed that as yet. So thank you.
JOYCE:
Great! Erica, thank you and it sounds as though there's been great opportunity that's come out of it for the service and certainly the role of palliative care in these crisis situations is certainly not a lot to do but very important. We...Jane, I'm interested to hear from you now. And we know that communicating these changes to each other that the changes that we might see in a resident to friends and family is really important, to help support loved ones in their bereavement or in their acceptance of change. And we've heard a little bit about the visiting from family and friends and we... Keen to hear what you think, what advice would you give to staff to ensure that they're communicating well between themselves, with the residents themselves and also with the residents' family and friends? And mention particularly in regards to end of life care where we're challenged by sometimes, that communication not being in person. But what other ideas have you got?
JANE NEWBOUND:
Thanks Joyce. A few things to consider with regard to communication in the sector. One is the use of technology that we hadn't really used a lot as effectively in the past and because of the circumstances with the COVID-19 outbreak, we're now saying we're used to things like telehealth, Zoom, making Skype, making things like that. So, in order, to keep families involved and participating in decision making, use of those levels of technology is really quite critical. But one of the things that if we take it back a little step, one of the things, one of the principles that I have...
(DOG BARKING)
I'm so sorry that's my dog in the background.
One of the principles that I have with regard to aged care and communication is start of from the very, very basic point of, what is it that the individual or their representative actually knows or understands about the condition? What is it that they actually want to know? And how do they want that information? Not everybody who has a loved one in an aged care facility might want daily contact. They might just want to have that opportunity to ring in once a week or do what they were previously doing with visits. So it might not even be, ya, I mean frequent, sort of, contact. But, you and I know, that there are some families who will want to be there 24/7 and are gonna want frequent and engaged conversations. So always start of with, How are you today? What's happening? Let's have a chat about Mum. So start of with that whole, sort of, in that lovely, calm relaxed approach. Ask them what it is that they're concerned about and where you can alleviate those fears or concerns that should be critical. One of the things these families, if they can't see the person, they will be really concerned about how mum or dad is managing in the aged care facility. So use a video-link and if you've got somebody who doesn't feel comfortable actually having a Zoom meeting, there's nothing stopping you taking a little video and sending that to them to say, Thought you'd like to see, this is mum today. She was actually having morning tea with..." Or engaging in a particular activity, and take a small video and send that to them. Just a reinforcement that everything's going OK, life is ticking over. So families once again just needing to reinforce that, what does the family know? What do they want to know? And how do they want that information? And from there, you can look at designing a visiting or communication platform for your families. You will probably have to look at something about booking in time for visits or Zoom meetings. So, hopefully, you've got some staff that can help accommodate those requests that families might have. When it comes to actually looking at communication amongst the team, it's really, really critical that we make sure that everybody is actually involved in that. If we look at who are these that participate in the provision of care in an aged care facility, obviously there's your nursing staff and your care staff but we need to make sure that we're encouraging the participation of activities and leisure life-styles programs. They are amazing at the work that they do with redirecting and keeping them socially interactive and engaged. But also think about things like your cleaning staff, your hospitality staff, your kitchen staff, maintenance, gardening. Whoever it is that is kind of your team needs to be involved. Laundry, all of those things. So make sure everybody knows what's going on and their role that they have to play. With regard to communication about specific care leads of residents. Historically, we've had the opportunity that we didn't quite hand over time. But, I think, it's really critical that we point out that in a lot of private sector aged care, we actually don't have hand over time for a lot of the case So you have to come up with a system that works for you. But make sure everybody is on that same page. Everybody is working towards the same goal and everybody knows what it is I have to be on the lookout for. So if you have anything different or changes, how they'll record that information back. So clear communication through whatever handover you may have, whether you have a printed handover that's given to your staff or whether your using an IT-based clinical document patient system that actually carries the notes or advice the staff of the things that they'll need to do in that shift. Whatever the system you have, make sure it's working really, really well. Use of memos, use of information, staff meetings, those kinds of things are critical to keep everybody engaged and on that same page. When we're talking about the COVID outbreak, we're not just talking about the clinical care of bereavement, we're talking about things like the infection control and management procedures and protocols that are in place in a facility. And that's something that everybody needs to (INAUDIBLE). So clear open lines of communication, making sure things are really clearly documented. I know, sometimes we don't use care plans quite in the way that we should because they're often too long and often a little bit of a work of fiction. And I'm only just saying that with my tongue in my cheek factitiously, since they sometimes are. Please make sure that what we're doing is giving the right information and making sure that everybody's got access to it. If you're not gonna read a 20-page care plan, how are you going to give that information to your next shift? And that would differ from every facility that you actually go to and work at. So you need to make sure that systems and clear lines of communication are clearly articulated and everybody is aware of them. Thanks, Joyce.
JOYCE:
Thanks, Jane. And really great tips there. And I actually loved...really know from the roles... the many, many roles that we have in our team in a residential aged care facility. I'm going to add a little bit more to our case study and then I'm gonna invite Steven to share his experiences. The next part of our case study is that Jack is supported by his daughter Carol. She needs to visit him two to three days per week. And his grandchildren would come once a month. He has another son Robert who lives in Brisbane, who visits twice a year. And Jack has had little contact with Robert. Jack's wife died five years ago from cardiac failure in the local hospital. So, we certainly know Jack and his family very well. And Steven, I know in preparing for today where he talks a little bit about your role as a volunteer in residential aged care services. And we're really interested to hear any thoughts and ideas that you might have about how volunteers might support residents in this time of different visiting options but also generally, particularly as residents come to their end of life.
STEVEN PETERSON:
OK, in a time such as the present when visiting residents by volunteers is either not permitted or is very limited, including no volunteer visits. Unfortunately, it becomes a bit more incumbent on staff at the aged care facility to step into the breach, and especially for someone like Jack who obviously is deteriorating. And I feel that there's two aspects to this. Firstly, I think there is an increasing need to help Jack maintain his usual routine as much as he's physically able to and wants to. Including keeping him up with his walking as much as he'd like to do that. Help guiding him to the dining room so that he can be maintaining the routine of eating as well as possible and, of course, having the contact with other residents at the dining table. And help him participate in any activities that he normally participates in such as exercises or singing or whatever lifestyle people at these centres do. The second aspect to this situation is that it's essential as has already been touched on to help Jack maintain contact with the people he normally is in contact with and particularly family. So, in this situation, we want to try and facilitate contact by the daughter that you just mentioned Jess, Jane, Perhaps if necessary ask her to have a flu injection if that might be required and obviously, disinfect upon her arrival. Setting up meetings between her and Jack in his room or a section of the facility which can be cordoned off and be made reasonably private. Also, encourage Robert to make a trip to Melbourne from Brisbane. Clearly the time is limited, so he'll want to be sure to see his father again. And also, as it's been touched on, make use of technology and this really is essential these days, to bring Jack's family into his room. So, Skype for one to ones between family members. Zoom for whole family gatherings wherever they might be. If Jack doesn't have a computer of his own let him use one of the facilities whether a laptop be brought into his room or he be set up in a separate area within the facility. And the same can be said for volunteers. I've spoken by phone to a number of the people I normally visit over the last couple of months and the common theme from them is that they are missing their volunteers. And they're still asking you know, When are we going to see you again?" So, I don't see why Skype sessions can't be set up individually between a resident and myself, for example. And also other activities I normally do is I spend about half an hour, 40 minutes reading to a group of residents in the lounge room area. So, why can't I be set up now to read the newspaper here in my home and that be shown on a screen in that lounge area so that the residents are receiving the same service as I normally provide? So, basically I'm sure Jack needs all the assistance that he can get to keep up with his everyday requirements and activities. Particularly his eating, particularly getting around and the social connectedness. I think that is absolutely crucial. Thanks very much.
JESSICA SIMIONATO:
Thanks, Steven. There we are. There some creative ideas there and I think that's been the flavour of things, isn't it? that we learn to be creative in these times. So, we've come to our final question. So, just a reminder that if you have got questions in the audience please pop those into the chat box and then we'll get to those in the next section. Jane, the last one is over to you again. We understand that due to the COVID-19 pandemic many GPs and other Allied Health services or support services are offering Telehealth consults. We've mentioned that already today. Do you have any advice for facilities about how they might best utilise local resources to develop relationships to support the provision of good end of life care at this time? And we probably should preface that it's not just at this time, it's all of the time how we might use those resources?
JANE NEWBOUND:
Thanks Jess. Absolutely, utilising and accessing those support services in your region is critical. And the most important thing is that you actually know what are the services available in my region because it's different in every part of Melbourne, in every part of Victoria. So, the blessed thing for us in metro area is that we can have access to community-based palliative care service providers. We can have access to residential in reach teams who are doing an amazing job during this COVID situation and your GPs. Now, some of them I know are reluctant to visit but are utilising things like Telehealth more often. But also, some of them are coming out and doing their weekly reviews and visits and follow up as business as usual for them. So, I think it's really critical to find out, what are the services in my region? How do I contact them? What's the process of referral? And then looking at ways in which you can maximise and utilise those services to support you. It's critical that we recognise the primary physician as the GP but sometimes we need to bring in those other support services to help the residents, and we should be using them as often as we possibly can if we need them. So, I think develop a relationship with those services. Get to know them. Get to know the staff that work in them and then you don't feel quite as uncomfortable ringing up and saying, "Hey, I've got someone I really would like to have chat about." So, don't be afraid to contact the services just to talk about, what are my options here? It's not just about saying, "I need someone, I'll refer her," and get someone out. It might be you just need to have that opportunity to chat. I think the involvement of Telehealth has been spectacular. I think we should be encouraging its use beyond the current pandemic and I think it then opens up opportunities for the future for things like having teleconferences with geriatricians that maybe you haven't got geriatricians that are coming and visiting your facility. It means that maybe we can have case conferences and discussions with multiple people being in the room. And I think that is gonna be advantageous for all residents to have access to that kind of environment. From the physical and resource perspective, particularly in the private sector, it would be lovely to see some resource investment so that you've got actually all of those things available to you. You actually can get things like a webcam that attaches to your big screen TV and then dial into Zoom and Skype via your mobile phone that you can actually connect. It means you've got a much bigger picture. Now, for people that have visual or hearing disturbances or deficits, having a bigger picture means they're more likely to actually engage in a conversation. So, also too it means that if there's someone who's doing an assessment on the other end that that picture is much clearer for the person. They're more likely to react or respond when an assessment is going on. I know some places have been blessed and they're very, very lucky in that they have a room dedicated and set up for Drs that can come in and do assessments or any basic care that might be required there, and so they've actually invested in having laptops and webcams and things like that in that room and that makes life so much easier if you've got a dedicated space to have teleconference or Telehealth. But alternatively, nothing wrong with a trolley with a laptop on top. And I just really reinforce in this time of infection control issues, please make sure that we're cleaning it appropriately and please make sure all staff know how to clean and look after any equipment that you've got available. Thanks Jess, ta.
JESSICA SIMIONATO:
Great, thanks Jane. I've haven't seen any questions come through but we did touch on the notion of referral to palliative care and opening up that conversation particularly when residents are deteriorating. Could you talk us through what a facility needs to do if they want to engage a palliative care service and how they might go about doing that? Of course, understand that there may be differences in regions.
JANE NEWBOUND:
Absolutely, Jess. Probably one of the things we need to be aware of is the fact that historically we've left referral to another service far too late in the aged care sector. So, we often have left referrals to when somebody's actually entered that imminently dying phase, and I think it's really important that we recognise that in aged care these days, the residents are far more complex than they were even 20 years ago. We've got people with multiple medical conditions and it's really, really important that we maybe get early referral into those support services. Now, they might not be doing all that much if we do an early referral but it might be that they at least on the books and then they can ring in once a month and say, How's things going, what's happening here?" And it just helps everybody be a little more prepared for maybe the inevitability of what's going to happen with that person. So, good relationships, early referral. Ring up and have a chat and see what's going on and what it is you might need to do for this particular person. And work collaboratively to develop a really
(AUDIO DISTORTS) management plan. So, everybody knows what it is that I'm gonna have to do for this person. Early referral, don't be afraid to call and have a chat. Utilise those services that are available to you and start getting things prepared. So, work with your GPs, (INAUDIBLE) he's prescribing, you wanna have those medications available after hours and on weekends because that's invariably when people decide to get very unwell. And then accessing Drs and things at that point can be really problematic. So, (INAUDIBLE) GP prescribing, have the meds on site if possible if you don't have an Impro system and getting prepared and ready. And that then also comes back to what we were talking about before with communication it's often is families are unprepared for the inevitability that's going to occur. And it's often then insisting in those last couple of days of life, Can we please send them to hospital?" Yes, we need to be doing everything. And what we need to reinforce to people that we can bring the expertise to our facility and we can do everything that is appropriate for that resident in our facility with their level of support. So, I think it's around that whole thing of expectations, when things might happen, being prepared is the critical component of it. Thanks Jess.
JESSICA SIMIONATO:
So, Penny, anything to add from a medical point of view there? Is there something else to add?
PENNY COTTON:
I guess I would echo what Jane's saying about the value of early referral to palliative care. So, where we work, our regional consult teams are often the ones who would go into the residential aged care services, and we really believe in that brief intervention. So, often we'll come in when the residents are deteriorating, or when they're admitted to a service and we'll do a bit of an overview which gives us that background as Jane says so that later on when we're called again to come and see that resident, we've got that knowledge. We know who's important for that resident, and we've have pictures, and we come in and go, OK, that is a significant difference. And we'll also find that that's important in establishing relationships with residential aged care services. So it's often that we're there, either during a telehealth at the moment or when we were going on-site, and now we are going back on-site, but it's, we often get that question about, "OK, and I've got this other resident and I'm just thinking about," and they'll talk through something. And I think that value of that relationship and that value of that sharing and developing those things are important. So that's where, I think Erika said it, too. It's about just pick up the phone and ring, so we might say, Yes, you're doing everything fine. And that's OK, too. And I don't think any of us are gonna dismiss you and say, Oh, that was a waste of my time. It never is a waste of our time. So I think, that early intervention, we can help with that anticipatory stuff, we can help with some of those conversations around advanced care planning, and particularly at the moment where we're doing that via telehealth, often, like I think about that Jack, often that tele helping is a great way to re-engage (AUDIO DISTORTS). We've had some great experiences where we have re-engaged those into said relative because we are better at reaching out, rather than have them reach in. But I think it's about how particularly at the moment, using all of that support services because we don't want our residents to be neglected during this high conflict time.
JESSICA SIMIONATO:
Thank you, Penny. And someone has just approached a question, Are GPs using telehealth more as well? And I think we've heard from a number of you that in particular regions, there is an increased use of telehealth. Yeah, Erika, you mentioned that before. And, perhaps Erika, did you do anything particular from the palliative care service to connect with local GPs to understand who was providing telehealth services?
ERIKA FISHER:
Sorry, Jess. Can you repeat that? You were breaking up a little bit.
JESSICA SIMIONATO:
Yes! Oh my apologies. So did you do, anything in particular, to connect with GPs (DOG BARKS)
to understand if they were providing telehealth to the residents?
ERIKA FISHER:
Yes, actually, it's been a big learning curve for us and we actually started asking the community because a lot of our patients are outside (INAUDIBLE), and they're on farms, and GPs don't visit. So that was such a great opportunity for us to start it with our palliative care doctor, was asked in the homes and do it that way. And now we have, you know, changed over or broadened it within the aged care facilities because currently, our local GPs, most of them are telephonic anyway. And as we know, they, the preference is those patients outside in the community are being seen, too and then, the GPs really depends on the aged care nurses and staff to feedback if there's any issue. So that was a really good way of doing that, and we're using Healthdirect at the moment for telehealth.
JESSICA SIMIONATO:
Fantastic. Thank you. To give people a little bit of time to perhaps post some questions through the chat box, we have about, around about ten or 11 minutes left today, so plenty of time for questions.
Give people some typing time.
Whilst your doing that, I wondered if someone from our panel wanted to comment around bereavement support. It's certainly nerve-wracking with the palliative care sector of the last, little while, and, in a year, probably leading up to this as well but bereavement has been a big focus and thinking about how we best support families and patients and residents in their bereavement. So perhaps, Penny, if you wanna kick it off for a medical point of view, but if, just around how we might provide bereavement support and if there's any differences at the moment?
PENNY COTTON:
I think bereavement support has always been challenging because how do you rebuild that with the proper people and how do you identify families who may need that support? I think that has been a challenge, but we also do acknowledge the bereavement support of the staff because, you know, you do know these residents so well. They are a part of your life, and the volunteers, as Steven said, they're at the... (AUDIO DISTORTS), ...make connections with these people. I think that is where referral to palliative care services can help. And if, where community palliative care services are involved, they can then also access the support services, so when where they're kind of have some more (AUDIO DISTORTS) of how they organise residential aged care services.
JESSICA SIMIONATO:
Yes. Thanks, Penny.
ERIKA FISHER:
Yes. The restrictions of visitors to the aged care facilities certainly have a huge impact on the grief and bereavement. We have had incidences where families have contacted us and also support staff to the aged care's contacted us where people have been, have deteriorated and there has been restrictions in place, and the families needed that support. So we actually were quite involved in getting those key people for communication in place in aged care, so that they can facilitate it. And it's been a process and it has improved but there's still some challenges to support those families and actually, have a family meeting, get those families into the aged care facilities when people deteriorate. And then also, consult and see if those patients are comfortable, are they being seen to, and if there's the end of life plan in place. So we have been busy a little bit more in getting involved in that. And our processes to the service is not as strict. We like conversations. We like staff to call us up. We invite community to come and talk to us if there's any issues as well, providing that there's confidentiality, providing, if possible, that the residents are aware of that. So, a lot of times, our advice and guidance is more informal to the staff. They might call up and say, "Look, I've got this issue. What do I do," rather than asking for, you know, formalised referral. And we find with their corridor conversations with staff, we pick up, you know, things earlier and getting in there earlier in the piece.
JESSICA SIMIONATO:
Thanks, Erika.
ERIKA FISHER:
Thank you.
JESSICA SIMIONATO:
There is a question around, Have palliative care clinicians or GPs had issues answering residential aged care facilities because of the need to provide evidence of flu vacc and, Penny, I think, you've, you've got a answer to share with us on that.
PENNY COTTON:
So this has been, those who have been allowed to re-enter residential aged care facilities, that has been one of the things that has delayed entering for a few times. So it has been an important thing to get that correct evidence that took a little while for that to come through from our flu vaccination program. And Andrea's right. In some of the residential aged care facilities, you know, you just show them the bit of paper and they'll have a glance, and that others are wanting more formal documentation and they're actually looking at that and some, there are some wanting copies of that so that we can... So we're proactively goin' in and go through all of those records for each member of our team so that we can respond quite quickly. And once the GPs have had the flu vaccination in their own practice, and so they have ready access to that information, but I think it is important as palliative care providers so if there's anyone who is entering residential aged care, to be planning actively for that because it is such an important part of protecting our residents.
JESSICA SIMIONATO:
Great. Thanks, Penny. And there is this some more question that some threw around strategies for families to be involved with touching the diseased resident, particularly if they have died with COVID-19? If anybody has got anything to add on that, that's great. If not, we can take that away and there is some guidance on the Department website around handling of diseased bodies, and our working groups were involved in being part of that. If anybody feels comfortable to comment on that one...
PENNY COTTON:
Is this about the medication?
JESSICA SIMIONATO:
No. But if family were to want to kiss the person after they had diseased, and for example, and they were positive for COVID-19, what strategies might we use instead...it's a very tricky question, I think. (LAUGHS)
ERIKA FISHER:
It is a tricky question, absolutely. We've had some discussions with the local undertakers and they have got their guidelines as well. So what we say in terms of that is that if somebody, rather if, the community side and the aged care side, but what the staff are being said is, if somebody dies and it's COVID, that needs to be relayed to the undertakers. The family has to be prepared and say that, unfortunately, with cultural and religious customs that includes washing and handling the body, that is advised against. If the diseased has to be moved in some way or other, full PPEs have to be doffed and planned in that. And that's part of the procedure anyway. Before the undertakers come in, the family needs to decide if there's any jewellery or anything personally on the diseased that needs to be removed. If the person or the diseased has got a syringe driver in, that has to be removed. That needs to be removed because they will double bag the body and it will not, the bag will not be opened. Once they have closed it, they have closed it. And the undertakers ask that there should be nobody in the room when they come and get the diseased. And there has to be a 1.5 metre social distancing. That's as far as we have.
JESSICA SIMIONATO:
Right. Thank you, Erika. It's a very delicate issue and I now will direct people that there is published advice on the Department's Coronavirus website around that big issue. So we can perhaps, share that link following this webinar. Are there any other questions?
Alright. Well, we are almost at the end of our time together. And I want to thank everybody for their time today, and their expertise in discussing this topic. We do ask those of you who are online today, that when the webinar finishes, there is a brief survey for you to complete. This survey helps us know how the webinar went and what we might do next. And we also would encourage you to subscribe to the Chief Health Officer Update to Coronavirus, and also to look at the dedicated Coronavirus website on the Department of Health and Human Services website. There is an "Aged Care" title there, which many of you may be aware of. And also, please connect with your local palliative care service. They are always there to help, and particularly, in National Palliative Care Week, let's celebrate the great work that palliative care does, and the way that they can support you is aged care services. So, we'll leave it there, we'll thank everybody for their time. A round of applause, and a virtual round of applause perhaps, and I wish you a very lovely afternoon.
JESSICA SIMIONATO:
Good afternoon, everyone. My name is Jessica Simionato and I am the Senior Project Officer in the Centre of Clinical Excellence of Older People, at Safer Care Victoria. On behalf of the Department of Health and Human Services, a very warm welcome to everyone online, and thank you very much for joining in today's webinar for Victorian residential aged care services titled, Palliative Care Within Residential Aged Care During the COVID-19 Pandemic'. Before we begin today, I'd like to start by acknowledging the traditional owners of the many lands in which we're meeting and pay my respects to their Elders past and present, and the Aboriginal Elders who may be joining us today. Before we start, there are a couple of housekeeping things to cover. Not all the presenters represent Safer Care Victoria or the Department of Health and Human Services. The views expressed in this webinar are that of the presenters whom we thank for their generous time today in sharing their knowledge and expertise. We expect the webinar to run for around 60 minutes, including some dedicated time for Q and A at the end.
You may ask questions of the presenters throughout the webinar via the chat box, and we'll do our best to respond to these during the webinar. Our webinar will be presented as a panel presentation today and we'll direct those questions directly for people as we go. And finally, if you're experiencing any technical issues, please feel free to contact Redback helpdesk or type your problem into the chat box. So our panel of experts for today. So we have Penny Cotton joining us. Doctor Penny Cotton is a palliative care physician with the Grampians Regional Palliative Care Team and Ballarat Health Services. Penny is also the Deputy Director of Medical Student Education for the University of Melbourne Rural Clinical School. And welcome, Penny. Jane Newbound is the Aged Care Project Manager at the Southern Metropolitan Region Palliative Care Consortium. Thank you, Jane for joining us. Jane has been a registered nurse for 36 years and in the last 20 years has focused on working in the aged care sector. So, an experienced voice for us today. Erika Fisher is also joining us, and she is the Palliative Care Nurse Consultant and Manager at Western District Health Services. She's a registered nurse in general community psychiatry and midwifery. And she has 30 years experience as a nurse in a vast range of specialist services across three countries. And finally, Steven Peterson is joining us today as well. And Steven is a Consumer Representative for Safer Victoria and will today share his experiences from the perspective of volunteering in aged care services. So thank you, Steven. Before we kick off into our panel discussion, we, as we have done in many of these webinars to date, I wanted to give you a update on the current Coronavirus situation. This brief update comes from the Chief Health Officer's Update and I am provided via email daily, of which all of you can register to receive. And we would encourage you to do so. So, my apologies, disappeared from in front of me. Excuse me, one moment.
So, as of 27 May, 2020, the total number of Coronavirus cases in Victoria is 1,618. This is a net increase of 8% to previous report on 26 May. We had two new cases linked to the Lynden Aged Care outbreak and some others are still under investigation. There are 183 cases that have been acquired in Victoria where the source of infection is unknown, and that is an increase of one since the prior report. We have eight people in hospitals, three in intensive care, and 19 deaths, sadly. There have been 183 confirmed cases in healthcare workers and for this report, that's an increase of one. Happily, there's been 470,000 test results received by the department since 1 January this year. And that's the increase of over 33,000 since the day before this report. So, some good testing numbers still occurring. If people would like for more information, of course, there's updates daily and also, the Department of Health and Human Services dedicated Coronavirus webpage. So, apologies. OK. Excuse me while I just get through here.
OK! So, onto our panel discussion today. So, palliative care, just to set the scene is the active, holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially, of those near the end of life. It aims to improve the quality of life for patients, their families, and their caregivers. And this week, for those of you who don't know, it's in fact, National Palliative Care Week, with the theme, More than you think. So we're really pleased to bring you this webinar topic today and celebrate that it is Palliative Care Week, and the opportunity to share knowledge about the role of palliative care and particularly that in aged care context. To work through today's questions, we are also going to read a quick case study, and just to put things into context for you as we speak today. So, Jack is an 82-year-old retired builder living in your residential aged care facility. Jack has Alzheimer's dementia, prostate cancer, and a history of cardiac disease.
He is usually ambulant with a four-wheel frame. He often does lapses a hallway during the day or finds a chair in the sun room looking out at the garden. He needs regular prompting and reorientating, but still answers simple questions when he's asked. He has urinary incontinence but he manages that with continence aid. Staff have noticed a change in Jack over the past few months. He comes out of his room less, he is not mobilising as well, and he is needing a little bit more help to transfer and shower. They've also noticed that he's lost five kilos of weight in the past three months. And he previously would make his own way to the dining room for meals, but now he's requiring supervision to do that. In the past few days, he seems less interested in eating. He spends more time in bed or in his chair in his room. He will acknowledge staff when they speak to him, but engages less in conversation than previously. And so, as we heard in that case study, the staff have noticed some changes in Jack. And I'm gonna direct this first question over to you, Penny. So from a medical point of view, what are the key things that might indicate deterioration? And also, we're interested to hear what considerations there are in this current circumstance, in the COVID-19 pandemic? Or if you've, we're worried a resident has COVID or because of the impact on the health system, if they needed care for another reason? So over to you, Penny.
PENNY COTTON:
Hello. I guess, as many of the participants would know, that it's often the subtle changes in our residents that indicates some are deteriorating. And it's picking up these subtle changes...
(AUDIO DISTORTS)
...facility where you've got a visiting shift, so you've got lots of different staff, lots of people coming and going. And I think, particularly, at the moment where family (AUDIO DISTORTS)
present in our facility, then I think, we've lost their eyes and ears, and even on our palliative care ward, I feel that raise of burden of, what they're trusting us to be their eyes and ears, and to pick up those subtle changes and to think about those things. And so, I think, that is a significant change at the moment where we don't have those extra sets of eyes who know that patient well, who could tell that something is not right. And so, I think, it's about trusting the staff who know the residents, who have that feeling that something has changed, something is not right. And it could be subtle. And even talking our own gut instincts that Jack's not who he'd normally was. So things like he's engaging less, he's not coming out of his room that much, he's spending more time resting, losing weight which is, I guess, a lot of our residents, residents who have poor prognostic signs, is losing appetite, less mobile, all of those subtle things, project they're quite obvious. But over, you know, busy shift for over a week or two weeks, or three weeks, they're often harder to be, and I think we're finding that as families return to facilities now, that sometimes they're noticing quite significant changes and they can be quite distressed about that, I think that's been the challenge as the restrictions has eased. And I think, it's a challenge that is ongoing to make sure that we are thinking about those subtle changes, including the fact with the senior residents, thinking about, well, what were they doing a week ago? What were they doing a month ago? And what are they doing now? And then, we (AUDIO DISTORTS)
JOYCE:
Sorry, Penny. We've kind of lost you, your audio there. So I'm just gonna bring us back to Jess.
JESSICA SIMIONATO:
Thank you. Great. Sorry, Penny. We did lose your audio there for a brief moment. But I think, you were certainly summarising that those subtle changes that we might see in our residents over time can be missed when we are in a busy shift and particularly, recently, when we've lost the eyes and ears of our friends and family visiting, and so, a benefit of having some lightening of the restrictions is to have, have those extra eyes and ears, and to be aware of the subtle changes in our residents. While we get Penny sort of repair audio... Oh, you're back! This is fantastic! (LAUGHS)
Was there anything else you wanted to add there, Penny?
PENNY COTTON:
So I guess that we're thinking about subtle changes in our residents, we do have to ask that question, could it be COVID? And we do have to think about that 'cause it can present very subtly in our residents. And even right now, at lower rates of community transmission, we do still have to ask that question and go through the process as well, being and know all of the things that that comes with. But I guess, it's just so important from a public health point of view and protecting the rest of our residents to go through that process. And that as that other challenge then of when you've got a resident who's deteriorating and now they're being swabbed, and now the family can't come in and how do we manage that as a community and as a service? Or could it be that he's depressed? Because if the family visiting or could it be that his other underlying medical condition is deteriorating?
JESSICA SIMIONATO:
Great! Thanks, Penny. And so, Erika, you are a palliative care nurse. And I'm interested to hear if you could talk us through the support the palliative care service might provide and in this situation? And if you've had to alter the way you've delivered care because of COVID-19? Yeah, over to you.
ERIKA FISHER:
Thank you, Jess, for inviting me. So in the Western District, there are eight residential aged care facilities in our catchment area, and palliative care plays an integral part of the COVID response. So, as a palliative care team, our response was to draft the pandemic plan for aged care. So what does the pandemic plan look like? We have divided it into four S's under stuff, staff, space, and systems. And that's how we set out education as well. So what does that look like under stuff? So we looked at aged care and looked at what are the things that they really need to be COVID ready. So we looked at the equipment and we found that we are really in shortage of things like syringe drivers, oxygen concentrators and all to do with your symptom management. We've identified that the palliative care drugs in aged care, there has been a ... Not every aged care facility has full access to the palliative care drugs. So we looked at and we compiled a emergency drug kit for palliative care within aged care. So all those facilities under district health now has palliative care emergency drug kits. And also consumables, if we need to have syringe drivers and (INAUDIBLE) in place, we developed a 'grab and go pack', which is easy to use when you're in full gown and you pick it up, you use and you discard. Next thing is staff. We have to look at support for those aged care staff. Because in the region, those staff they know their residents. And they sort it with the residents in restrictions of visitors. So we look through, support through education. We did a series of COVID's in the palliative area. And aged care, the aged care approach patients that we did with the aged care staff. There was a series of upskilling workshops that was run and it included (CROSSTALK)
these questions on syringe driver management. We look at space. Currently, we've got one funded palliative care bed and we have to look at how to maximise that space. So we have negotiated with aged care that we, actually, have more than one bed in there for a non-COVID patient to make sure that if there's an outbreak in the hospital that they don't go directly into a queue. So that would be direct admission to the palliative care bed, in the adjacent aged care facility. And then also systems, which identified key people in aged care to really zoom into updated advance care plans and goals of care for all the residents in there.
It's still in process and a lot of work has been done by aged care. And also look at the care to answer the dying patient. Outcome from all of that, we now have a supportive palliative care symptom management for the non-ventilated, COVID-19 patients. We've got that in draft form now. We have changed the policy on visitation to include residential aged care during COVID-19 crisis. So we have input in that with the patient policy. We now have consumer service offices in all our aged care facilities, to assist and facilitate the change or adapting visiting to aged care residents. Because our rule is if they are palliative or there's a change in their condition, they are allowed apparently to have visitors. There has been refurbishing standards of facilities to accommodate visiting rooms, and it looks fabulous by the way. And also we had through the COVID funding additional devices for communication has been purchased including iPads, speakers and phones and also integrated Wi-fi into television. So the type of message here is and it was important for aged care staff to know this is that all residents in a crisis of COVID will be cared for. What that looks like will differ and any, you know, all aspects is care, whether that is invasive ventilation, or ward-based treatment, or symptom management and end of life care, it all is...that's all key. Have we altered our care to aged care residents? We certainly took the opportunity to look broader and we now have health direct, a telehealth speaker for palliative care, so we can support those aged care staff better, which is really a big thing for us in the region. We have improved our resident communication and take up resident care plans for aged care staff, where we assist the patient and then they can continue with that key plans for the residents. And... We have... We have maintained our consultant as well within aged care. We haven't changed that as yet. So thank you.
JOYCE:
Great! Erica, thank you and it sounds as though there's been great opportunity that's come out of it for the service and certainly the role of palliative care in these crisis situations is certainly not a lot to do but very important. We...Jane, I'm interested to hear from you now. And we know that communicating these changes to each other that the changes that we might see in a resident to friends and family is really important, to help support loved ones in their bereavement or in their acceptance of change. And we've heard a little bit about the visiting from family and friends and we... Keen to hear what you think, what advice would you give to staff to ensure that they're communicating well between themselves, with the residents themselves and also with the residents' family and friends? And mention particularly in regards to end of life care where we're challenged by sometimes, that communication not being in person. But what other ideas have you got?
JANE NEWBOUND:
Thanks Joyce. A few things to consider with regard to communication in the sector. One is the use of technology that we hadn't really used a lot as effectively in the past and because of the circumstances with the COVID-19 outbreak, we're now saying we're used to things like telehealth, Zoom, making Skype, making things like that. So, in order, to keep families involved and participating in decision making, use of those levels of technology is really quite critical. But one of the things that if we take it back a little step, one of the things, one of the principles that I have...
(DOG BARKING)
I'm so sorry that's my dog in the background.
One of the principles that I have with regard to aged care and communication is start of from the very, very basic point of, what is it that the individual or their representative actually knows or understands about the condition? What is it that they actually want to know? And how do they want that information? Not everybody who has a loved one in an aged care facility might want daily contact. They might just want to have that opportunity to ring in once a week or do what they were previously doing with visits. So it might not even be, ya, I mean frequent, sort of, contact. But, you and I know, that there are some families who will want to be there 24/7 and are gonna want frequent and engaged conversations. So always start of with, How are you today? What's happening? Let's have a chat about Mum. So start of with that whole, sort of, in that lovely, calm relaxed approach. Ask them what it is that they're concerned about and where you can alleviate those fears or concerns that should be critical. One of the things these families, if they can't see the person, they will be really concerned about how mum or dad is managing in the aged care facility. So use a video-link and if you've got somebody who doesn't feel comfortable actually having a Zoom meeting, there's nothing stopping you taking a little video and sending that to them to say, Thought you'd like to see, this is mum today. She was actually having morning tea with..." Or engaging in a particular activity, and take a small video and send that to them. Just a reinforcement that everything's going OK, life is ticking over. So families once again just needing to reinforce that, what does the family know? What do they want to know? And how do they want that information? And from there, you can look at designing a visiting or communication platform for your families. You will probably have to look at something about booking in time for visits or Zoom meetings. So, hopefully, you've got some staff that can help accommodate those requests that families might have. When it comes to actually looking at communication amongst the team, it's really, really critical that we make sure that everybody is actually involved in that. If we look at who are these that participate in the provision of care in an aged care facility, obviously there's your nursing staff and your care staff but we need to make sure that we're encouraging the participation of activities and leisure life-styles programs. They are amazing at the work that they do with redirecting and keeping them socially interactive and engaged. But also think about things like your cleaning staff, your hospitality staff, your kitchen staff, maintenance, gardening. Whoever it is that is kind of your team needs to be involved. Laundry, all of those things. So make sure everybody knows what's going on and their role that they have to play. With regard to communication about specific care leads of residents. Historically, we've had the opportunity that we didn't quite hand over time. But, I think, it's really critical that we point out that in a lot of private sector aged care, we actually don't have hand over time for a lot of the case So you have to come up with a system that works for you. But make sure everybody is on that same page. Everybody is working towards the same goal and everybody knows what it is I have to be on the lookout for. So if you have anything different or changes, how they'll record that information back. So clear communication through whatever handover you may have, whether you have a printed handover that's given to your staff or whether your using an IT-based clinical document patient system that actually carries the notes or advice the staff of the things that they'll need to do in that shift. Whatever the system you have, make sure it's working really, really well. Use of memos, use of information, staff meetings, those kinds of things are critical to keep everybody engaged and on that same page. When we're talking about the COVID outbreak, we're not just talking about the clinical care of bereavement, we're talking about things like the infection control and management procedures and protocols that are in place in a facility. And that's something that everybody needs to (INAUDIBLE). So clear open lines of communication, making sure things are really clearly documented. I know, sometimes we don't use care plans quite in the way that we should because they're often too long and often a little bit of a work of fiction. And I'm only just saying that with my tongue in my cheek factitiously, since they sometimes are. Please make sure that what we're doing is giving the right information and making sure that everybody's got access to it. If you're not gonna read a 20-page care plan, how are you going to give that information to your next shift? And that would differ from every facility that you actually go to and work at. So you need to make sure that systems and clear lines of communication are clearly articulated and everybody is aware of them. Thanks, Joyce.
JOYCE:
Thanks, Jane. And really great tips there. And I actually loved...really know from the roles... the many, many roles that we have in our team in a residential aged care facility. I'm going to add a little bit more to our case study and then I'm gonna invite Steven to share his experiences. The next part of our case study is that Jack is supported by his daughter Carol. She needs to visit him two to three days per week. And his grandchildren would come once a month. He has another son Robert who lives in Brisbane, who visits twice a year. And Jack has had little contact with Robert. Jack's wife died five years ago from cardiac failure in the local hospital. So, we certainly know Jack and his family very well. And Steven, I know in preparing for today where he talks a little bit about your role as a volunteer in residential aged care services. And we're really interested to hear any thoughts and ideas that you might have about how volunteers might support residents in this time of different visiting options but also generally, particularly as residents come to their end of life.
STEVEN PETERSON:
OK, in a time such as the present when visiting residents by volunteers is either not permitted or is very limited, including no volunteer visits. Unfortunately, it becomes a bit more incumbent on staff at the aged care facility to step into the breach, and especially for someone like Jack who obviously is deteriorating. And I feel that there's two aspects to this. Firstly, I think there is an increasing need to help Jack maintain his usual routine as much as he's physically able to and wants to. Including keeping him up with his walking as much as he'd like to do that. Help guiding him to the dining room so that he can be maintaining the routine of eating as well as possible and, of course, having the contact with other residents at the dining table. And help him participate in any activities that he normally participates in such as exercises or singing or whatever lifestyle people at these centres do. The second aspect to this situation is that it's essential as has already been touched on to help Jack maintain contact with the people he normally is in contact with and particularly family. So, in this situation, we want to try and facilitate contact by the daughter that you just mentioned Jess, Jane, Perhaps if necessary ask her to have a flu injection if that might be required and obviously, disinfect upon her arrival. Setting up meetings between her and Jack in his room or a section of the facility which can be cordoned off and be made reasonably private. Also, encourage Robert to make a trip to Melbourne from Brisbane. Clearly the time is limited, so he'll want to be sure to see his father again. And also, as it's been touched on, make use of technology and this really is essential these days, to bring Jack's family into his room. So, Skype for one to ones between family members. Zoom for whole family gatherings wherever they might be. If Jack doesn't have a computer of his own let him use one of the facilities whether a laptop be brought into his room or he be set up in a separate area within the facility. And the same can be said for volunteers. I've spoken by phone to a number of the people I normally visit over the last couple of months and the common theme from them is that they are missing their volunteers. And they're still asking you know, When are we going to see you again?" So, I don't see why Skype sessions can't be set up individually between a resident and myself, for example. And also other activities I normally do is I spend about half an hour, 40 minutes reading to a group of residents in the lounge room area. So, why can't I be set up now to read the newspaper here in my home and that be shown on a screen in that lounge area so that the residents are receiving the same service as I normally provide? So, basically I'm sure Jack needs all the assistance that he can get to keep up with his everyday requirements and activities. Particularly his eating, particularly getting around and the social connectedness. I think that is absolutely crucial. Thanks very much.
JESSICA SIMIONATO:
Thanks, Steven. There we are. There some creative ideas there and I think that's been the flavour of things, isn't it? that we learn to be creative in these times. So, we've come to our final question. So, just a reminder that if you have got questions in the audience please pop those into the chat box and then we'll get to those in the next section. Jane, the last one is over to you again. We understand that due to the COVID-19 pandemic many GPs and other Allied Health services or support services are offering Telehealth consults. We've mentioned that already today. Do you have any advice for facilities about how they might best utilise local resources to develop relationships to support the provision of good end of life care at this time? And we probably should preface that it's not just at this time, it's all of the time how we might use those resources?
JANE NEWBOUND:
Thanks Jess. Absolutely, utilising and accessing those support services in your region is critical. And the most important thing is that you actually know what are the services available in my region because it's different in every part of Melbourne, in every part of Victoria. So, the blessed thing for us in metro area is that we can have access to community-based palliative care service providers. We can have access to residential in reach teams who are doing an amazing job during this COVID situation and your GPs. Now, some of them I know are reluctant to visit but are utilising things like Telehealth more often. But also, some of them are coming out and doing their weekly reviews and visits and follow up as business as usual for them. So, I think it's really critical to find out, what are the services in my region? How do I contact them? What's the process of referral? And then looking at ways in which you can maximise and utilise those services to support you. It's critical that we recognise the primary physician as the GP but sometimes we need to bring in those other support services to help the residents, and we should be using them as often as we possibly can if we need them. So, I think develop a relationship with those services. Get to know them. Get to know the staff that work in them and then you don't feel quite as uncomfortable ringing up and saying, "Hey, I've got someone I really would like to have chat about." So, don't be afraid to contact the services just to talk about, what are my options here? It's not just about saying, "I need someone, I'll refer her," and get someone out. It might be you just need to have that opportunity to chat. I think the involvement of Telehealth has been spectacular. I think we should be encouraging its use beyond the current pandemic and I think it then opens up opportunities for the future for things like having teleconferences with geriatricians that maybe you haven't got geriatricians that are coming and visiting your facility. It means that maybe we can have case conferences and discussions with multiple people being in the room. And I think that is gonna be advantageous for all residents to have access to that kind of environment. From the physical and resource perspective, particularly in the private sector, it would be lovely to see some resource investment so that you've got actually all of those things available to you. You actually can get things like a webcam that attaches to your big screen TV and then dial into Zoom and Skype via your mobile phone that you can actually connect. It means you've got a much bigger picture. Now, for people that have visual or hearing disturbances or deficits, having a bigger picture means they're more likely to actually engage in a conversation. So, also too it means that if there's someone who's doing an assessment on the other end that that picture is much clearer for the person. They're more likely to react or respond when an assessment is going on. I know some places have been blessed and they're very, very lucky in that they have a room dedicated and set up for Drs that can come in and do assessments or any basic care that might be required there, and so they've actually invested in having laptops and webcams and things like that in that room and that makes life so much easier if you've got a dedicated space to have teleconference or Telehealth. But alternatively, nothing wrong with a trolley with a laptop on top. And I just really reinforce in this time of infection control issues, please make sure that we're cleaning it appropriately and please make sure all staff know how to clean and look after any equipment that you've got available. Thanks Jess, ta.
JESSICA SIMIONATO:
Great, thanks Jane. I've haven't seen any questions come through but we did touch on the notion of referral to palliative care and opening up that conversation particularly when residents are deteriorating. Could you talk us through what a facility needs to do if they want to engage a palliative care service and how they might go about doing that? Of course, understand that there may be differences in regions.
JANE NEWBOUND:
Absolutely, Jess. Probably one of the things we need to be aware of is the fact that historically we've left referral to another service far too late in the aged care sector. So, we often have left referrals to when somebody's actually entered that imminently dying phase, and I think it's really important that we recognise that in aged care these days, the residents are far more complex than they were even 20 years ago. We've got people with multiple medical conditions and it's really, really important that we maybe get early referral into those support services. Now, they might not be doing all that much if we do an early referral but it might be that they at least on the books and then they can ring in once a month and say, How's things going, what's happening here?" And it just helps everybody be a little more prepared for maybe the inevitability of what's going to happen with that person. So, good relationships, early referral. Ring up and have a chat and see what's going on and what it is you might need to do for this particular person. And work collaboratively to develop a really
(AUDIO DISTORTS) management plan. So, everybody knows what it is that I'm gonna have to do for this person. Early referral, don't be afraid to call and have a chat. Utilise those services that are available to you and start getting things prepared. So, work with your GPs, (INAUDIBLE) he's prescribing, you wanna have those medications available after hours and on weekends because that's invariably when people decide to get very unwell. And then accessing Drs and things at that point can be really problematic. So, (INAUDIBLE) GP prescribing, have the meds on site if possible if you don't have an Impro system and getting prepared and ready. And that then also comes back to what we were talking about before with communication it's often is families are unprepared for the inevitability that's going to occur. And it's often then insisting in those last couple of days of life, Can we please send them to hospital?" Yes, we need to be doing everything. And what we need to reinforce to people that we can bring the expertise to our facility and we can do everything that is appropriate for that resident in our facility with their level of support. So, I think it's around that whole thing of expectations, when things might happen, being prepared is the critical component of it. Thanks Jess.
JESSICA SIMIONATO:
So, Penny, anything to add from a medical point of view there? Is there something else to add?
PENNY COTTON:
I guess I would echo what Jane's saying about the value of early referral to palliative care. So, where we work, our regional consult teams are often the ones who would go into the residential aged care services, and we really believe in that brief intervention. So, often we'll come in when the residents are deteriorating, or when they're admitted to a service and we'll do a bit of an overview which gives us that background as Jane says so that later on when we're called again to come and see that resident, we've got that knowledge. We know who's important for that resident, and we've have pictures, and we come in and go, OK, that is a significant difference. And we'll also find that that's important in establishing relationships with residential aged care services. So it's often that we're there, either during a telehealth at the moment or when we were going on-site, and now we are going back on-site, but it's, we often get that question about, "OK, and I've got this other resident and I'm just thinking about," and they'll talk through something. And I think that value of that relationship and that value of that sharing and developing those things are important. So that's where, I think Erika said it, too. It's about just pick up the phone and ring, so we might say, Yes, you're doing everything fine. And that's OK, too. And I don't think any of us are gonna dismiss you and say, Oh, that was a waste of my time. It never is a waste of our time. So I think, that early intervention, we can help with that anticipatory stuff, we can help with some of those conversations around advanced care planning, and particularly at the moment where we're doing that via telehealth, often, like I think about that Jack, often that tele helping is a great way to re-engage (AUDIO DISTORTS). We've had some great experiences where we have re-engaged those into said relative because we are better at reaching out, rather than have them reach in. But I think it's about how particularly at the moment, using all of that support services because we don't want our residents to be neglected during this high conflict time.
JESSICA SIMIONATO:
Thank you, Penny. And someone has just approached a question, Are GPs using telehealth more as well? And I think we've heard from a number of you that in particular regions, there is an increased use of telehealth. Yeah, Erika, you mentioned that before. And, perhaps Erika, did you do anything particular from the palliative care service to connect with local GPs to understand who was providing telehealth services?
ERIKA FISHER:
Sorry, Jess. Can you repeat that? You were breaking up a little bit.
JESSICA SIMIONATO:
Yes! Oh my apologies. So did you do, anything in particular, to connect with GPs (DOG BARKS)
to understand if they were providing telehealth to the residents?
ERIKA FISHER:
Yes, actually, it's been a big learning curve for us and we actually started asking the community because a lot of our patients are outside (INAUDIBLE), and they're on farms, and GPs don't visit. So that was such a great opportunity for us to start it with our palliative care doctor, was asked in the homes and do it that way. And now we have, you know, changed over or broadened it within the aged care facilities because currently, our local GPs, most of them are telephonic anyway. And as we know, they, the preference is those patients outside in the community are being seen, too and then, the GPs really depends on the aged care nurses and staff to feedback if there's any issue. So that was a really good way of doing that, and we're using Healthdirect at the moment for telehealth.
JESSICA SIMIONATO:
Fantastic. Thank you. To give people a little bit of time to perhaps post some questions through the chat box, we have about, around about ten or 11 minutes left today, so plenty of time for questions.
Give people some typing time.
Whilst your doing that, I wondered if someone from our panel wanted to comment around bereavement support. It's certainly nerve-wracking with the palliative care sector of the last, little while, and, in a year, probably leading up to this as well but bereavement has been a big focus and thinking about how we best support families and patients and residents in their bereavement. So perhaps, Penny, if you wanna kick it off for a medical point of view, but if, just around how we might provide bereavement support and if there's any differences at the moment?
PENNY COTTON:
I think bereavement support has always been challenging because how do you rebuild that with the proper people and how do you identify families who may need that support? I think that has been a challenge, but we also do acknowledge the bereavement support of the staff because, you know, you do know these residents so well. They are a part of your life, and the volunteers, as Steven said, they're at the... (AUDIO DISTORTS), ...make connections with these people. I think that is where referral to palliative care services can help. And if, where community palliative care services are involved, they can then also access the support services, so when where they're kind of have some more (AUDIO DISTORTS) of how they organise residential aged care services.
JESSICA SIMIONATO:
Yes. Thanks, Penny.
ERIKA FISHER:
Yes. The restrictions of visitors to the aged care facilities certainly have a huge impact on the grief and bereavement. We have had incidences where families have contacted us and also support staff to the aged care's contacted us where people have been, have deteriorated and there has been restrictions in place, and the families needed that support. So we actually were quite involved in getting those key people for communication in place in aged care, so that they can facilitate it. And it's been a process and it has improved but there's still some challenges to support those families and actually, have a family meeting, get those families into the aged care facilities when people deteriorate. And then also, consult and see if those patients are comfortable, are they being seen to, and if there's the end of life plan in place. So we have been busy a little bit more in getting involved in that. And our processes to the service is not as strict. We like conversations. We like staff to call us up. We invite community to come and talk to us if there's any issues as well, providing that there's confidentiality, providing, if possible, that the residents are aware of that. So, a lot of times, our advice and guidance is more informal to the staff. They might call up and say, "Look, I've got this issue. What do I do," rather than asking for, you know, formalised referral. And we find with their corridor conversations with staff, we pick up, you know, things earlier and getting in there earlier in the piece.
JESSICA SIMIONATO:
Thanks, Erika.
ERIKA FISHER:
Thank you.
JESSICA SIMIONATO:
There is a question around, Have palliative care clinicians or GPs had issues answering residential aged care facilities because of the need to provide evidence of flu vacc and, Penny, I think, you've, you've got a answer to share with us on that.
PENNY COTTON:
So this has been, those who have been allowed to re-enter residential aged care facilities, that has been one of the things that has delayed entering for a few times. So it has been an important thing to get that correct evidence that took a little while for that to come through from our flu vaccination program. And Andrea's right. In some of the residential aged care facilities, you know, you just show them the bit of paper and they'll have a glance, and that others are wanting more formal documentation and they're actually looking at that and some, there are some wanting copies of that so that we can... So we're proactively goin' in and go through all of those records for each member of our team so that we can respond quite quickly. And once the GPs have had the flu vaccination in their own practice, and so they have ready access to that information, but I think it is important as palliative care providers so if there's anyone who is entering residential aged care, to be planning actively for that because it is such an important part of protecting our residents.
JESSICA SIMIONATO:
Great. Thanks, Penny. And there is this some more question that some threw around strategies for families to be involved with touching the diseased resident, particularly if they have died with COVID-19? If anybody has got anything to add on that, that's great. If not, we can take that away and there is some guidance on the Department website around handling of diseased bodies, and our working groups were involved in being part of that. If anybody feels comfortable to comment on that one...
PENNY COTTON:
Is this about the medication?
JESSICA SIMIONATO:
No. But if family were to want to kiss the person after they had diseased, and for example, and they were positive for COVID-19, what strategies might we use instead...it's a very tricky question, I think. (LAUGHS)
ERIKA FISHER:
It is a tricky question, absolutely. We've had some discussions with the local undertakers and they have got their guidelines as well. So what we say in terms of that is that if somebody, rather if, the community side and the aged care side, but what the staff are being said is, if somebody dies and it's COVID, that needs to be relayed to the undertakers. The family has to be prepared and say that, unfortunately, with cultural and religious customs that includes washing and handling the body, that is advised against. If the diseased has to be moved in some way or other, full PPEs have to be doffed and planned in that. And that's part of the procedure anyway. Before the undertakers come in, the family needs to decide if there's any jewellery or anything personally on the diseased that needs to be removed. If the person or the diseased has got a syringe driver in, that has to be removed. That needs to be removed because they will double bag the body and it will not, the bag will not be opened. Once they have closed it, they have closed it. And the undertakers ask that there should be nobody in the room when they come and get the diseased. And there has to be a 1.5 metre social distancing. That's as far as we have.
JESSICA SIMIONATO:
Right. Thank you, Erika. It's a very delicate issue and I now will direct people that there is published advice on the Department's Coronavirus website around that big issue. So we can perhaps, share that link following this webinar. Are there any other questions?
Alright. Well, we are almost at the end of our time together. And I want to thank everybody for their time today, and their expertise in discussing this topic. We do ask those of you who are online today, that when the webinar finishes, there is a brief survey for you to complete. This survey helps us know how the webinar went and what we might do next. And we also would encourage you to subscribe to the Chief Health Officer Update to Coronavirus, and also to look at the dedicated Coronavirus website on the Department of Health and Human Services website. There is an "Aged Care" title there, which many of you may be aware of. And also, please connect with your local palliative care service. They are always there to help, and particularly, in National Palliative Care Week, let's celebrate the great work that palliative care does, and the way that they can support you is aged care services. So, we'll leave it there, we'll thank everybody for their time. A round of applause, and a virtual round of applause perhaps, and I wish you a very lovely afternoon.
Reviewed 28 October 2021