Australia’s ageing population means there is an increasing number of people aged 65 years or older. As most deaths in Australia occur among older people (66% of deaths occur in people aged 75 years or over), aged care staff and services are increasingly providing care for clients and residents who are coming to the end of their life. ELDAC (End of Life Directions for Aged Care) aims to support the aged care sector by providing information and toolkits for palliative care and advance care planning, and by facilitating linkages between aged care, palliative care and primary care.

Early in the development of ELDAC, we reviewed the national palliative care and advance care planning policies and the frameworks used in major palliative care projects. As there are already well-established programs of work in palliative care and advance care planning, understanding their core elements would help provide consistency between sectors and activities. This document review aimed to identify the core elements of palliative care and advance care planning that were being used consistently across Australia. The findings would form the basis for a care model that could help staff and services to consider and manage key care issues in the last phase of life when a person progresses toward death. Twelve major documents were examined including National Palliative Care Standards and Service Development Guidelines (Palliative Care Australia); National Consensus Statement on End of Life (Australian Commission for Safety and Quality in Healthcare); National Palliative Care Strategy (Australian Department of Health); and six projects funded under the National Palliative Care Program.

A review of these policies and project practice frameworks showed there were common core elements in identification, care planning and care delivery. In essence, the key processes were:

• Advance care planning, to be aware of the wishes and preferences of the individual;
• Recognising end of life by proactively considering whether the person could have changes indicating that death is foreseeable;
• Assessing palliative care needs, to enable comprehensive identification and planning of care;
• Providing palliative care including delivering care, reassessing needs and monitoring for changes;
• Working together as a team to meet the specific needs of the individual;
• Responding to deterioration so that changing needs are identified, and care plans updated to meet new care needs;
• Managing dying with an appropriate plan for the last days of life; and
• Bereavement, so that family, friends, residents and staff are supported with grief and loss.

This model is represented in the ELDAC Care Model (112kb pdf). The model is a simple and coherent guide that enables care providers to understand aspects of care and to recognise that care needs may change over time. It is sufficiently flexible that it can be used to support ELDAC project activities at the individual, team, service and system level.

We have used this model in most components of the ELDAC project. It is also the basis for the organisation of content in the Residential Aged Care, Home Care and Primary Care toolkits. It forms the framework for content in the Information and Services section of the website. Staff working in the sector engagement project also introduce services to the ELDAC Care Model, and it is being used in the work on a digital dashboard.

If you want to find out more about the ELDAC Care Model, there is a handy infographic that provides an overview. You can print or share this with others in your service. Find out more about ELDAC at www.eldac.com.au.

Prof Jennifer Tieman Director, Matthew Flinders Fellow, Research Centre in Palliative Care, Death and Dying