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ROYAL COMMISSION: Begging to stay in hospital and challenges of palliative care

The fourth day of the Perth hearings for the Royal Commission into Aged Care Quality and Safety listened to a case study about poor pain management and palliative care provided to a man with high care needs while in an aged care facility.

Shannon Ruddock told the Royal Commission she once begged a hospital not to send her father back to his nursing home because she lacked confidence in their care. [Source: Aged Care Royal Commission]
Shannon Ruddock told the Royal Commission she once begged a hospital not to send her father back to his nursing home because she lacked confidence in their care. [Source: Aged Care Royal Commission]

Shannon Ruddock gave a statement explaining a breaking point where she begged a hospital not to return her father to Alkira Gardens Nursing Home, where he was based in 2017, because she didn’t have confidence they would properly take care of him.

Ms Ruddock’s father, Mr Vincent Paranthoiene, had developed Spindle Cell tumour with a terminal diagnosis while he was in the facility. 

It took nearly three months to be recognised there was something wrong and was only found by his daughter after she noticed a large lump on his ribs.

In many cases, Ms Ruddock found that her father’s pain was not properly managed by the facility, and even with the help of a visiting palliative care nurse practitioner, didn’t seem to keep up on his planned pain management.

Ms Ruddock says, “I believe my father was neglected by Alkira and they could not provide him with adequate palliative care. 

“My concerns are that there were not enough staff in Alkira to care for residents such as my father with complex needs and the staff that were there were not trained to provide appropriate palliative care including how to administer PRN (as needed) medications.

“I also believe that palliative care is specialised care and that residential aged care facilities that offer it should go through a rigorous accreditation process and ensure that staff delivering this care understand the care needs of each patient. I constantly felt like the staff at Alkira did not understand that they were caring for someone who was dying.”

Whenever Mr Paranthoiene was taken to the hospital for emergencies or illness, his daughter found he was treated much more appropriately, with higher quality pain management and holistic care, than when he was at Alkira.

Ms Ruddock described the pain management as a constant “battle” for herself just to upkeep in the aged care facility. She felt that she was doing pain assessments for her father in the place of the facility that should have been undertaking this at least once a day.

Another issue Ms Ruddock was unhappy about was around the funds Mr Paranthoiene was receiving, which didn’t seem to be properly provided towards his pain management plan.

“In my experience, there seemed to be a discrepancy between how much the facility received to care for my father and the care he actually received,” says Ms Ruddock.

“My concern is that the discretionary powers granted to facility managers to direct funds as they see appropriate is open to abuse and if abused, can put high care residents at risk of neglect.”

Pain management difficult to manage in aged care settings

Joshua Cohen, Palliative Care Nurse Practitioner, Calvary Health Care Kogarah, attended the day's proceedings giving a statement about his services provided within aged care facilities and what he sees as a visiting practitioner.

He was also the palliative care nurse practitioner that attended to Mr Paranthoiene. 

He said in many cases the staff at aged care facilities were unsure how to appropriately provide palliative care, which can be as simple as assessing pain during other tasks.

“I would say that pain management in residential aged care can often be difficult to manage. The care setting can be a tricky space,” says Mr Cohen.

“The lack of education and knowledge amongst staff around pain management, how to assess pain appropriately, how to manage the medications appropriately, both regular and as required medications, can present some barriers to good pain management. 

“When it comes to cancer pain management in residential aged care, that isn’t often the type of pain we’re managing there. In the instance with Mr Paranthoiene, that was absolutely the type of pain we were managing and it was, in this care setting, difficult to manage.”

Mr Cohen attends up to 4,000 beds across 66 aged care facilities through his palliative care service work at Calvary Health Care Kogarah public hospital.

In his experience, managing pain is not an issue he has only witnessed at Alkira, but seemed to be common throughout many residential aged care facilities.

Also similar to Alkira is the fact that many registered nurses and staff are overwhelmed with the workload they have to handle, which would probably hinder appropriate pain management.

Mr Cohen also stated that there is no easy solution to fixing this because residential aged care is a very complex and difficult space. There needs to be a combination of systems in place to provide good outcomes for palliative approaches in the facilities.

Mr Cohen says, “It’s certainly about quality over quantity. But I don’t actively engage in the number of staff... that are assigned to a particular patient load. There are times when I ask, “How many people are you looking after?” to the registered nurse.

“Normally, it's an overwhelming amount, and I know that when I ask them to accompany me on an assessment, I’m aware they’re stretched in the capacity to do that. 

Another concern raised by Mr Cohen was his opinion that aged care facilities were lacking in their identification of a resident needing palliative care.

Documentation shortfalls and inadequate pain assessments

The Royal Commission next heard from John Leong, a Compliance and Development Managers for The Sisters of Our Lady of China Health Care Pty Ltd.

Mr Leong acknowledged that palliative care and pain management was something that Alkira provided, but in the case of Mr Paranthoiene, it was not implemented adequately.

Counsel Assisting Erin Hill suggested that there were shortfalls in records, which meant that, on some occasions, Mr Paranthoiene was in pain.

However, Mr Leong says that since there were no proper documentation on pain assessments or records for those highlighted days, he could not speculate whether Mr Paranthoiene was or wasn’t in pain.

Mr Leong did agree that there was poor documentation on “some occasions” which was inadequate. He says that staff have since been trained to rectify this issue.

Alkira Gardens received a sanction from October 16-23, 2017, when Mr Parathoiene was in the facility, which Mr Leong believed did reflect very poorly on the facility.

He also agreed that there was not enough staff working at the nursing home while Mr Paranthoiene was a resident.

The last day of hearings is today, Friday, June 28, at 9.30am AWST in Perth, WA.

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