Case Conferences in Residential Aged Care

Understand and incorporate the needs and preferences of the older person and their family by:

• Consulting with the older person, family members, significant others and care workers to identify and share information regarding changing needs and preferences.
• Respecting the lifestyle, social context, cultural and spiritual needs of the older person.
• Applying the principles and aims of a palliative approach in development of a care plan for the older person.
• Providing emotional support using effective communication skills.
• Understanding and supporting the advance care planning process.
• Identifying and reflecting upon the potential impact of delivering a palliative approach to self, care workers and family carers.

Be able to access all relevant local health, social and volunteering services by:

• Establishing and maintaining relevant networks to ensure appropriate referral of older people to services from within and outside your organization.
• Advocating for the older person regarding service delivery.
• Effectively communicating the purpose and availability of services to the older person and family.
• Developing and implementing routine procedures to ensure that allocated service delivery continues to match the older person's and their family’s requirements.
• Maintaining effective communication with all services involved in delivering a palliative approach and care to the older person.
• Regularly reviewing the changing needs of the older person to ensure they are met.

Apply the principles and aims of a palliative approach in caring for the older person by:

• Encouraging the older person and their family to share information about the person’s needs and preferences.
• Respecting the older person’s lifestyle, social context, cultural and spiritual needs.
• Regularly checking and following the care interventions as documented in the care plan.
• Identifying and reflecting upon own emotional responses to delivery of a palliative approach.
• Seeking support when needed.

Observe, monitor and report the older person's and family’s needs to the case manager by:

• Referring needs and issues expressed by the older person and family to the appropriate healthcare or allied health member of the team.
• Recognising and reporting any signs of the older person’s deterioration and increased needs.
• Recognising and reporting any increased emotional needs of the older palliative resident persons back to the case management team.

A palliative care case conference may take a few weeks to organise.
Planning is essential.

Case Conference Checklist

If an older person is involved with a palliative care service, they may already have structures and processes to support palliative care case conferences. Contact the service provider to find out how they organise case conferences for patients.

A structured process can make the case conference more useful.

Introductions (take the time to orientate the participants)

• Have the RAC staff and GP introduce themselves and you and invite others to introduce themselves stating their role on the team.
• Review the meeting’s goals and clarify specific decisions that will need to be made before the case conference ends.
• Establish ground rules for conducting the conversation in a non-patronising or threatening way.
  For example, you might begin:
  ‘We would like to hear from all of you. However, if possible, could one person please speak at a time?
  Each person will have a chance to ask questions and express their views.’

Identify the legal decision maker

• Remember that if the older person is competent, they are the legal decision maker.
• If there are nominated substitute decision makers attending and the older person is competent, the substitute decision maker may assist but is not to be the person deferred to for decision-making unless the older person indicates that this is their preference.
• If the older person does not have decision-making capacity, then the designated substitute decision-maker or ‘person responsible’ should be referred to with regard to decision-making.

Determine what the older person / family already knows

• Have the GP ask: ‘What is your understanding of your current medical condition?'
• The GP should ask about the past one to six months: what has changed (eg, functional decline, weight loss, recent hospital admissions, changes to medications).
• The GP or residential aged care nurse should seek to identify the preferences of the older person and family regarding how much detail they wish to be told about the trajectory of dying with the illness.
• Review the current status, prognosis and treatment options for the specific disease(s).
• Allow all healthcare professionals to have their say about what they consider beneficial or non-beneficial treatment under the circumstances.
• Review any issues that arise from the older person, family or healthcare team members.
• Inquire about family circumstances and resources and what will be required from them in the remaining time that is left.
• Ask the older person and their family separately and in turn if they have any questions about the current status, prognosis and treatment options of the disease.

Decision-making (when the older person is competent)

• The GP should ask the older person: ‘What decision(s) about your healthcare, lifestyle or medical treatments are you considering?’
• The GP or residential aged care nurse should ask each family member: ‘Do you have questions or concerns about the plan being discussed?’
• Ask each family member: ‘How can you support the older person?’

Decision-making (when the older person is deemed not to have decision-making capacity)

• Ask each family member in turn: ‘What do you believe this person would choose if they could speak for themselves?’
• Ask each family member: ‘What do you think should be done?’
• Ask the family if they would like the case management team to leave the room to allow a private family discussion.
• When the care management team returns, confirm with the family the decisions that have been made.

When there is no consensus between parties at the case conference:

• Use time as an ally: schedule a follow-up conference in the near future.
• Try further discussion if time permits and people are agreeable:
  • ‘What values are your decisions based upon?'
  • ‘How will the decision affect you and other family members?'
  • ‘What would the resident say if they could speak?’
• Identify other resources to facilitate decision-making (e.g. spiritual / religious affiliations) CareSearch resources for nurses and palliAGED resources for family members.

Wrapping up the case conference

• Summarise consensus, disagreements and decisions.
• Outline action plan and the outline of the care plan.
• Caution against unexpected outcomes.
• Identify substitute decision maker or person responsible required for ongoing communication if the older palliative resident is not competent or does not wish to enter into further decision-making.

Writing it down
It is important to document the key issues and outcomes of the case conference as well as provide this information to participants of the conference:

• Complete a palliAGED has a Case Conference Summary form (226kb pdf)
• Offer a copy of the conference summary to the older person and/or family members, general practitioner and relevant others.
• Amend the person’s care plan to reflect the outcomes and action plan from the case conference.
• Provide any written information that you feel would assist the older person and/or family in relation to issues that were raised during the case conference.
• Add an entry to the resident's record that a case conference was held.

It should be made clear who is to be responsible for actions / tasks and when these actions/tasks are expected to be resolved or completed. Consider whether someone needs to be made responsible for follow up.

The Medical Benefits Scheme has a schedule of payments for GPs relating to organising and participating in case conferences. Eligibility is based on complex care or services provided to patients with chronic or terminal medical conditions from their usual GP. At least 2 other health care providers are required for a case conference and they must also meet eligibility requirements.
The MBS details are available at MBS Online.

Further information is available

• MBS Online website for explanatory notes and item descriptors for MBS items.
• Services Australia (Medicare) for inquiries regarding eligibility, claiming, fees and rebates
  • Patient enquiries Telephone: 132011
  • Provider enquiries Telephone: 132150

• CareSearch resources for nurses
• palliAGED resources for family members
• Palliative Care Australia
  • Multilingual resources
  • Resources about palliative care
• TIS National Interpreting services
• palliAGED has a Conference Planning Checklist (403kb pdf)