A new model for delivering palliative care in residential aged care

Palliative care in residential aged care is changing as Australia’s population ages and residents present with more complex conditions. Many people live with dementia, frailty, cancer, heart failure or chronic lung disease for years, then require skilled support as their health declines. Care needs to be available throughout that journey, not reserved for the final days of life.

A new model for delivering palliative care in residential aged care facilities places the resident, family and care team at the centre of a coordinated service. It combines early planning, regular clinical review, workforce education and reliable access to specialist advice. The aim is to make comfort, dignity and choice part of everyday care.

For Queensland providers, the model must work across metropolitan Brisbane, regional centres and rural communities. It should connect residential aged care facilities (RACFs) with general practitioners, community nursing, hospitals, pharmacists, allied health professionals and specialist palliative care teams, while respecting Aboriginal and Torres Strait Islander approaches to family, community and end-of-life care.

Start with early, person-centred planning

Palliative care should begin when a resident has an advanced or life-limiting illness, rather than after an emergency admission. A structured assessment can identify pain, breathlessness, nutrition concerns, mobility changes, anxiety, spiritual needs and the preferences of the person’s substitute decision-maker.

Advance care planning gives residents an opportunity to record what matters to them while they can still participate fully. This may include preferred place of care, hospital transfer decisions, resuscitation preferences and cultural or religious wishes. In Australia, documents such as Queensland’s Advance Health Directive and Statement of Choices can support clearer communication between residents, families and clinicians.

The process should be revisited when a resident’s condition changes. A short conversation during a routine GP review or case conference can prevent confusion later, particularly when an ambulance is called after hours. Clear records in the care plan and accessible electronic systems help ensure that a resident’s choices follow them between the RACF, hospital and community services.

Build a team around the facility

The core service can be led by a trained nurse within the facility, supported by a nominated GP and a specialist palliative care clinician. This “hub and spoke” arrangement allows the RACF to manage routine symptom control while accessing expert advice for complex pain, delirium, medication changes or difficult family discussions.

Regular multidisciplinary case conferences create a shared plan. Nurses, personal care workers, GPs, pharmacists, physiotherapists, social workers and spiritual care providers each contribute a different perspective. Personal care workers often notice subtle changes first, such as reduced appetite, altered sleep or withdrawal from activities, so their observations should be valued in clinical reviews.

Telehealth can extend specialist support to facilities outside Brisbane and to communities in regional Queensland. It is useful for medication reviews, family meetings and clinical supervision, although it should complement rather than replace face-to-face assessment. Services also need a clear escalation pathway for urgent symptoms, including who to call overnight and how to avoid unnecessary transfers to emergency departments.

Equip the workforce for confident care

A sustainable model depends on practical education, not a single training session. Staff need confidence in recognising deterioration, discussing goals of care, using pain and symptom assessment tools, providing mouth care and supporting families through grief. Education should be available during paid work time and reinforced through mentoring, short case discussions and reflective practice.

Residential aged care staff work under significant pressure, with changing rosters and different levels of clinical experience. Training therefore needs to be concise, accessible and relevant to everyday situations. Modules can cover opioid safety, non-pharmacological comfort measures, dementia and palliative care, culturally safe communication, and the distinction between expected end-of-life changes and treatable distress.

Workforce development should include emotional support for staff. Caring for a resident through death can be demanding, particularly when a team has known the person for years. Debriefing, peer support and access to employee assistance services can reduce burnout and help staff continue to provide compassionate care.

Connect funding, governance and evidence

Implementation requires more than goodwill. Facilities need defined roles, referral criteria, documentation standards, medication protocols and measures of quality. Governance arrangements should clarify clinical accountability, consent, privacy, after-hours coverage and the process for reviewing adverse events or hospital transfers.

Funding pathways can be complex across aged care, Medicare, hospital and community services. A local partnership can map existing resources and identify gaps rather than creating a parallel program. In Queensland, collaboration between a RACF, Hospital and Health Service, Primary Health Network, university and consumer representatives can help align priorities and support evaluation.

Research translation is central to making the model durable. Providers developing a pilot may benefit from the grant writing guide when framing a problem, identifying outcomes and showing how evidence will move into practice. Useful measures include symptom relief, resident and family experience, unplanned hospital transfers, use of advance care plans, staff confidence and whether care was delivered in the resident’s preferred setting.

Respect culture, place and family

Good palliative care reflects the resident’s identity and community. For Aboriginal and Torres Strait Islander residents, services should work with local Elders, Aboriginal health workers and family networks, recognising that cultural obligations and decision-making may not fit a standard Western clinical process. Interpreters and culturally safe communication are essential when English is not a resident’s preferred language.

Queensland’s geography also shapes access. A facility in Logan may connect quickly with metropolitan specialist services, while one in Toowoomba, Mount Isa or the Torres Strait may need scheduled outreach, telehealth and stronger local capability. Travel costs, workforce shortages and limited pharmacy access can affect how quickly medication and specialist advice are available.

Families often want to be closely involved, including through phone or video calls when distance prevents a visit. Clear, plain-speaking updates help avoid misunderstandings about prognosis and treatment. Saying that a resident is “getting weaker” or “approaching the end of life” may be more meaningful than relying on technical language, provided conversations remain respectful and sensitive.

A connected approach is the foundation for lasting improvement. Brisbane Diamantina Health Partners brings together health services, universities and research organisations to support collaboration, evaluation and the translation of evidence into better care. Partnerships of this kind can help RACFs test practical changes while keeping residents and families at the centre.

Residential aged care providers, clinicians, researchers and consumer representatives can begin by reviewing current end-of-life care, identifying one measurable gap and forming a local improvement team. With shared protocols, supported staff and meaningful evaluation, palliative care can become more timely, equitable and compassionate across Queensland.