The evolution of palliative care and the relevance to residential aged care: Understanding the past to inform the future
Article Outline
- Summary
- Introduction
- Years: 1000–1200
- Years: 1500
- Years: 1900s
- The changing perception of death in society
- Changes to morbidity and mortality
- International developments of the modern hospice
- Towards an open dialogue of death: repositioning the debate
- Australia and the evolution of palliative care
- Developments in New South Wales
- Developments in Victoria
- Developments in Queensland
- Developments in the other Australian states
- Social change, an emerging specialisation and government involvement
- What about dying in residential aged care?
- The requirements for a palliative approach in residential aged care units
- Why adopt a palliative approach?
- Tentative recommendations
- Conclusion
- References
- Copyright
Summary
Improving the experience of dying in residential aged care units became a significant project of the Australian Government’s National Palliative Care Program in 2004. This initiative resulted in an expectation that residential aged care facilities would adopt the recommended palliative approach to underpin service delivery. Recognising palliative care as a specialist area of health care practice is a recent development which has influenced the expectations of community and government. This paper traces the global history of palliative care and how historical factors influenced its development in Australia. This discussion presents an overview of the positioning of dying and death within society, explaining how with the shifting emphasis on care of the dying accordingly has been the focus on palliative care specialists. Care of the dying in residential aged care units has largely been overlooked in the context of specialist involvement. This paper acknowledges dying and death as occurring in residential aged care facilities, illuminating the advantages of adopting a palliative approach and offers recommendations.
Keywords: Nursing, Palliative approach, Palliative care, Residential aged care
Introduction
This paper presents a description of the history of European institutionalised palliative care nursing that influenced the development of care for the dying in Australia. The paper also describes how attitudes towards death have changed from being treated as a normal and accepted part of life to something dealt with away from public view. Currently, death is more openly discussed within the health care milieu. Although not an exhaustive review, this paper describes the chronological emergence of aspects of care of the dying within the literature. Care of the dying within residential aged care, including how palliative care might be better achieved in this setting, is then discussed. The paper concludes with recommendations for policy, practice and research in the residential aged care arena.
This discussion begins with a brief consideration of how society changed during the first millennium. European society shifted from an assortment of insular settlements to groups who embraced international trade (Dawson et al., 2004). With such change, society’s response to the sick and the dying was likewise transformed (Lascaratos & Poulacou-Rebelacou, 2000).
Years: 1000–1200
The rise of civilisations and increase in trade led Europeans to travel to the Far East using routes simultaneously traversed by religious groups. Results of this intermingling were shared religious and spiritual beliefs as well as the emergence of monastic outposts which provided sustenance and shelter to travellers, and provided spiritual guidance and solace to those who were sick, injured and dying (Lascaratos & Poulacou-Rebelacou, 2000). Religious groups throughout Europe adopted similar outposts thereby recognising care of the dying as necessary services for communities. This service, originally provided by religious orders, became known as hospice care. Leming and Dickinson (1990) describe hospitium, as a Latin term meaning hospitality, inn, or lodging, which was derived from the word hospes, meaning a host or guest.
Years: 1500
During the Holy Wars of the 14th century, the Knights Hospitallers of Rhodes adopted a practice of separating sick from dying patients as they recognised their different emotional and spiritual needs. Care of the dying involved prayer, the offering of solace, and religious rituals in preparation for death (Ramadge, 2000). In a number of countries, dying and death was considered to be a predictable progression in life’s natural cycle. Communities, within their social structure, became familiar and accepting of the sights of dying and death. Parker and Aranda, 1998a, Parker and Aranda, 1998b explain that “the medieval sense of death (was) familiar and known, [with] the embeddedness of the dying person in a community of shared values”.
Years: 1900s
In the 19th century, some writers suggest that the term hospice represented a shelter for the ‘chronically ill and disabled’ often overseen by religious orders prior to and into the 20th century (Chapman, 1999, Kuebler et al., 2002). Basic nursing care was provided in these hospices, however, the emphasis was centred on saving the person’s soul rather than the nursing care they received (Humphreys, 2001). Humphreys (2001, p. 17) maintains that “care of the dying occurred alongside care of the living” in England until the late 19th century.
Aries (cited in Parker and Aranda, 1998a, Parker and Aranda, 1998b) comments that some Christian faiths glorified the process of dying; however dying prior to the mid-1900s was for most, a promise of ‘salvation for the person’s soul,’ not for comfort in the dying process (Ramadge, 2000). The first recorded hospice known to have been set aside for the care of the dying was established in Lyons, France, in 1842, however, better known was the establishment of the hospice in Dublin, Ireland, in 1879, by the Sisters of Charity (Francis, 1998). Our Lady’s Hospice, as it was known, sought to provide “a place where patients could die with minimum pain, surrounded by supportive staff, family and friends” away from the hospital environment (Mattson, 2005, p. 3).
The changing perception of death in society
Lewis (2007) explains that the world of the living became disconnected from those who were dying in Victorian Britain. The 19th century saw the emergence of a social structure in England, whereby the wealthy employed servants to provide nursing care to the sick within their homes (Smith, 2001) because the voluntary hospitals of the time only provided care to those who could afford to pay and were unlikely to die (Francis, 1998). Humphreys (2001) suggests that the creation of the first institute for the dying in the late Victorian era physically separated the care provided to chronic and incurable patients from the respectable poor who were medically certified as dying. The move to institutionalised care acknowledged that dying patients had special medical, nursing and spiritual needs which could only be provided by trained staff in an institutional environment (Humphreys, 2001).
The middle classes employed extended family living together to provide nursing care to members who became sick, while the poor sought charity from philanthropically motivated individuals or religious groups to administer nursing care (Smith, 2001). The undeserving poor became destitute, dying in alleyways, poor house infirmaries, or on the streets. The plight of these individuals was shameful and undignified (Humphreys, 2001). These times were marked by fears of the poor being sent to workhouses or given a pauper’s funeral characterised by a lack of dignity, and buried in a shallow communal grave without markings and located in un-consecrated ground (Leming & Dickinson, 1990; Lewis, 2007). In these circumstances, families had no opportunity to mourn or perform rituals of remembrance (Humphreys, 2001).
Changes to morbidity and mortality
Educated medical practitioners expanded their knowledge during the 19th century, following developments in Post-Revolutionary France (Francis, 1998). Lewis (2007) describes how cancer replaced syphilis (the ‘red plague’) and tuberculosis (the ‘white plague’) in the 20th century, as a disease of modern Anglo-Saxon countries, although evidence of the disease from earlier times casts doubt on this origination date. Cases of hard tumors and ulcers of the skin, female breast and genitalia causing deaths as far back as 400 BC have been identified in Egyptian skulls from the first dynasty (Lewis, 2007). Lewis (2007) further identifies a greater interest and emphasis on medical research giving rise to laboratory-based, clinical biomedicine which necessitated alliances between laboratories, hospitals and clinical trials. Previously infectious diseases were controlled by prophylaxis, whereas cancer involved treatments that called for the development of research with organizations and government involvement (Smith, 2001).
Changes in morbidity and mortality in the mid- to late 1900s from fatal infectious diseases of rapid progression to chronic and life threatening diseases of longer duration, forced the shift from homecare to institutionalised care. People who were dying were classified as a group called “the dying”, which emerged as a social category according to Clark (cited in Payne et al., 2004, p. 39) and “necessitated the establishment of specialized institutions to care for their needs”. The hospital building explosion emphasizing scientific medicine (Payne et al., 2004) took a different direction in caring for the sick and dying. Dying patients became a constant reminder of failure, and were an embarrassment to the medical profession. As a consequence, specialist units were developed hiding the care provided to the dying from society’s view (Payne et al., 2004).
International developments of the modern hospice
One person who was inspired by the pioneers of the past to develop and improve nursing care for the dying within a holistic concept of care was Dame Cicely Saunders. Saunders, a nurse, an almoner, and trained medical practitioner founded St. Christopher’s Hospice in London in 1967. This institution was a hospice providing holistic care for the needs of the dying and education for health professionals on modern practices in delivering care, including the concept of pain as embracing social, emotional and spiritual suffering (Clark, 1999). While working as a social worker at St. Thomas’ Hospital, Saunders also worked as a volunteer nurse at St. Luke’s House (a ‘Home for the Dying Poor’) in the evenings. She noted that patients in this facility were “not heavily sedated by drugs, nor left with unrelieved pain” (Anon, nd, p. 3) and were alert and conversant with analgesia administered regularly, thus pre-empting pain. After qualifying as a doctor in 1957, Saunders worked at St. Joseph’s Hospice where she researched better pain management (Anon, nd).
Saunders was a pragmatic yet charismatic advocate for the needs of people at the end of life inspiring people across the world with her writing and extensive research. She espoused three key principles of excellence focusing on clinical care with an emphasis on nursing practice, education and research. Her first published work in The St. Thomas’s Hospital Gazette in 1958 gained an audience of like-minded people and led to the formation of an international network of colleagues in who actively sought to adopt her practices in delivering care to the ill/dying. This network involved North America, India, Ceylon, Australia, France, Switzerland, the Netherlands and communist Poland (Payne et al., 2004).
In 1963, Dr. Bernard Lytton, a urologist, invited Saunders to describe her research to medical students at Yale University in the United States of America (Mattson, 2005). Florence Wald was in attendance and soon began corresponding with Saunders (Mattson, 2005). Wald resigned her position at Yale to form a small group in New Haven which founded the first hospice program in the United States in 1974, The Connecticut Hospice (American Public Media, 2007).
Towards an open dialogue of death: repositioning the debate
It was perhaps Elizabeth Kubler-Ross, an American doctor, who gave the world permission to discuss in totality the subject of death and dying from her very personal accounts of her parents’ experiences and her ground-breaking workshops in death and dying (Kubler-Ross, 2003). It is interesting that both Kubler-Ross and Saunders were medical doctors, who thus provided credence within that profession for the plight of the dying in the mid-1960s. Yet, Saunder’s movement arose at a time when dying was beginning to be subsumed into modern medical developments that prolonged life, often in a burdensome way. While regarding death as a human event, and working to ensure people’s rights at the end of their life, she utilised medical knowledge to ensure dying was as comfortable as possible. As palliative care became a more accepted part of healthcare, the tension the acute and palliative care paradigm grew and remains to this day. Kearney articulates this concern when he states his worries of integrating “our expertise back into general medical care…In essence, I am afraid we may be in the process of selling our soul to the very medical model whose excesses have created the needs our specialty has set out to meet” (Australian and New Zealand Society of Palliative Medicine (ANZSPM), 1999, p. 1). This tension is also relevant when one considers the place of death in modern society and the degree to which it is acknowledged or not. For example, if death occurs in hospital and in relation to medical treatment, it is regarded as a failure; if death occurs in a home or residential aged care facility, it is more often seen as a conclusion to the person’s life, due to illness or age.
Australia and the evolution of palliative care
Francis (1998, p. 88) acknowledges the Indigenous peoples of Terra Australis Incognita (Australia) living in unison with nature and developing remedies from natural sources. Dying and death for Australian Aborigines lived on in the dream times, depicted in art works on rocks and in caves preserving the belief of an afterlife; a person’s right of passage through rituals, with separation of ‘men’s business’ from ‘women’s business’ (Francis, 1998). White colonization of Australia in 1788 destabilised traditional approaches to health care.
The delivery of nursing care to convicts and free settlers under colonial rule in Australia, necessitates mentioning two related events. Mary Aikenhead (later known as Sister Mary Augustine) lived in Cork, Ireland, and at the age of 25 she founded a new uncloistered order, the Irish Sisters of Charity. As ‘Mother Superior’ of this order, she wished to establish a hospital in Ireland, and thus dispatched three of the sisters to Paris to experience the work conducted at Notre Dame de la Pitie Hospital. The outcome of this visit was the establishment of St. Vincent’s Hospital in 1834, and Our Lady’s Hospice in Dublin, Ireland (Clark, 2000). Anecdotal evidence suggests that Mary Aikenhead first used the word ‘hospice’ to describe a place of rest along the journey to death, however the claim that they provided “the earliest involvement in traditional care of the dying in Australia” is undisputed (O’Connor, 2001, p. 67).
Developments in New South Wales
According to Francis (1998), the Bishop of Sydney, John Bede Polding, knowing the work of the Irish Sisters of Charity in caring for the poor and recognising the plight of the Sydney poor contacted Sister Mary Augustine to send some of her religious sisters to New South Wales to provide nursing care and spiritual solace (Francis, 1998, p. 97). The Irish Sisters of Charity arrived in 1838 (MacGinley, 1996), and conducted community work caring for the poor including the ill and dying. In 1890, they established a home for the dying in Sydney, named Sacred Heart Hospice (Kellehear, 2000). Caring for the chronically ill or aged is not separated in the literature; therefore there is an assumption that those who were chronically ill were not part of the delivery of care until they were deemed to be dying.
Although previously stating the plight of the poor and destitute, it is necessary to conceptualise care for the dying in a more contemporary context. The Anglican Church in Sydney opened three ‘Homes of Peace’, described as “often isolated institutions, professionally reinforcing the perception that these places were death houses” (Ramadge, 2000, p. 7). As a consequence of this observation, care of the dying has since remained inpatient focused (Ramadge, 2000). Two senior anaesthetists, Dr. Brian Pollard and Dr. Brian Dwyer, both at St. Vincent’s Hospital, influenced the development of understanding the needs of the dying patient in the acute sector. From these early beginnings, palliative care clinical nurse consultants joined the teams at Concord and Royal Prince Alfred Hospitals to assist ward staff in managing the person’s care. These specialist roles according to Kellehear (2000, p. 261) “developed skills in case management, education and evidence-based practice”.
Developments in Victoria
In Melbourne, Victoria, care for the sick and dying commenced in the 1850s with the establishment of the Melbourne City mission when, according to Smith (2001, p. 6), “concerned Christians responded to the needs of the poor and suffering who swelled the ranks of their city during the Victorian Gold Rush”. This embryonic agency visited and prayed with the poor and destitute, those judged as having strayed from the Christian faith; thus their souls were saved prior to death (Smith, 2001).
The Sisters of Charity (previously acknowledged) were invited to Melbourne by the Melbourne Archbishop Thomas Carr who was known for his sense of altruism (Smith, 2001). The Sisters opened St. Vincent’s Hospital in Fitzroy, Melbourne, providing care for all religious denominations and non-believers. It is purported that very limited funding from the government was received; the main revenue coming from public goodwill and donations, therefore the sisters vehemently protected their image of caring for all persons equally (Smith, 2001). The Sisters continued their work with the dying, opening Caritas Christi in Melbourne in 1938.
New developments occurred in the late 1970s when new approaches in caring for the dying where identified as necessary. Bethlehem (Little Company of Mary Hospital) had been providing inpatient hospice services for a number of years in Melbourne, though now a new concept of homecare service was to augment the institutionalised care. Melbourne City Mission in 1980 sent one of their staff to undertake a study tour of progressive hospices in both Canada and the United Kingdom. On returning to Australia, the reported findings were presented to the board, who then sought funding from the private sector and the Australian government (Smith, 2001). This money enabled Melbourne City Mission to pilot a 10-bed inpatient unit within their nursing home which is the first reference to aged persons and dying stated in the literature. The unit operated separately within the nursing home, opening in 1980 (Kellehear, 2000). Melbourne City Mission commenced a homecare service for the northern suburbs in 1981, often admitting dying patients from the homecare service directly to the unit.
Developments in Queensland
In Queensland, despite the Sisters of Charity funding Mount Olivet Hospice in 1957, the small population and expansive geographic distance encumbered the growth of palliative care specialist services and limited them to palliative care units within hospitals where the Commonwealth Medicare Incentive Packages of 1989 was channelled without consultation, according to Ramadge (2000). In major centres like Brisbane and Townsville, the Queensland Cancer Fund purloined charity funds for developing inpatient services (Ramadge, 2000, p. 10). Queensland appeared to have operated palliative care services in the cities and adopts District or Community nursing services to fulfil the needs of the dying in rural areas.
Developments in the other Australian states
Redpath (cited in Ramadge, 2000) states that other Australian States established hospices or units within hospitals to provide specialist palliative nursing care to patients. In Adelaide, South Australia, the Mary Potter Hospice opened in 1964 as part of Calvary Hospital. In Tasmania, an inpatient unit became part of the Hobart Repatriation Hospital in 1980. The Australian Capital Territory provided the public with a 17-bed Hospice in 1996. The vast regions of the Northern Territory serviced through the Commonwealth Palliative Care Program have a team in Darwin (created in 1993), to cover the immense distances to Alice Springs, Katherine and other centres. Recently, a 10-bed hospice in Darwin has augmented this service. In the Royal Perth Hospital, in 1977, Saunders inspired improved care within the oncology unit at the Mount Henry Hospital to “utilise some beds for those with a short life expectancy” (Redpath cited in Ramadge, 2000, p. 9).
From the early beginnings in each state of Australia, other units were established that provided nursing care reflective of modern practice. These units were initially constructed from the work of Saunders, but were tailored to Australian needs. The services were provided by appropriately trained staff working in specialist units (often supported by volunteers) who delivered care to patients with a medical diagnosis of cancer and who had 6
months or less to live. Care of the dying had become a specialty practice. However, people continued to die in a variety of settings; home, acute hospitals and residential aged care. Yet, these settings were neglected as policy makers focused on providing resources for specialised palliative care units.
Social change, an emerging specialisation and government involvement
The influence of caring for the dying, mainly through the work of Saunders, has been global. Her vision for clinical practice, research and education has inspired many initiatives like the first professional multi-disciplinary conference at the Southern Cross Homes in Adelaide in 1985 (Ramadge, 2000). This was followed by the first Chair in Palliative Medicine in 1987 established by Flinders University, Adelaide (Kellehear, 2000). Tasmania, in the mid-1980s, provided Clinical Nurse Consultants (CNCs) to assist the Palliative Care physician at the Royal Hobart Hospital. The Australian Association for Hospice and Palliative Care (now known as Palliative Care Australia) was formed in 1991 to be the national peak body.
In 1987, the Victorian Parliamentary Committee published the findings of an inquiry entitled Options for Dying with Dignity (Smith, 2001). The recommendations of this inquiry focused on the “patient’s right to oppose extraordinary and heroic attempts to keep them alive” (Smith, 2001, p. 45). Subsequently, this State passed the Medical Treatment Act (1988) which gave a person the right to refuse treatment (Johnstone, 2004), a move that was replicated in many other States over the next few years (Ramadge, 2000). While during the 1980s, the Australian government and various State governments had provided limited funding to the development of palliative care services. In 1989, the Australian government announced the Medicare Incentive Package which aimed to free up acute beds by funding ‘homecare palliative care programs’. This action was later augmented with a further injection of Australian government funding through the Palliative Care Program of 1993 “which amounted to some $1.5 million in Victoria alone” (Smith, 2001, p. 46). A joint project by the National Palliative Care Association and the Australian Council on Health Care Standards (ACHS) in 1994 developed the first guidelines for use by palliative care services entitled: Standards for Hospice and Palliative Care Provision (Ramadge, 2000). The guidelines covered specialist hospice or palliative care in home and inpatient settings for patients with a terminal illness, which at the time, was mainly focused on people dying of cancer. With this focus, there was little consideration of dying and death as a natural progression of life, thus the recommendations of these guidelines were not considered relevant for people dying in residential aged care.
What about dying in residential aged care?
The benefits of palliative care for patients and family members have been well acknowledged (Hudson & O’Connor, 2007), with many Asian countries presently adopting the palliative care concept (Anon, 2001). However, palliative care services continued to develop their expertise mostly around care of those dying from a predictable illness such as cancer. This may have been due to the extant body of expertise, but is perhaps linked to the ease of a predictable prognosis fitting into available funding models (O’Connor, 2001).
Over time, an increasing awareness developed around the seeming system inequities of palliative care services as readily available for a person prematurely dying in a palliative care service (home or hospice) and a person dying in residential aged care who may require the specialised skills of palliative care, but is unable to access them (O’Connor & Pearson, 2004). Significant work has been undertaken throughout the last decade to ensure equitable access to end of life care, regardless of where the person is dying (Foggatt et al., 2002, Grbich et al., 2005, O’Connor, 2001). This has required a generous sharing of the respective clinical and educational expertise of those who work in aged care and in palliative care in order to ensure the best care of older dying people. The ritualised practices of delivering care to the dying within the aged care sector have been challenged by moves to ensure access to expert care be made available to all in need.
The requirements for a palliative approach in residential aged care units
The demographics of an increasing ageing population in Australia (Australian Bureau of Statistics, 1998) supports the need for palliative care services to be available to persons, other than those medically diagnosed with cancer. Through the National Palliative Care Program, the government recognised that people with a chronic or life-limiting illness (besides those with a diagnosis of cancer) would benefit from the multi-disciplinary approach associated with the delivery of palliative care.
Ten years after the Standards of Hospice and Palliative Care were developed, the Australian government commissioned the Guidelines for a Palliative Approach in Residential Aged Care (Australian Government Department of Health and Ageing, 2004) with an expectation that the guidelines and standards would be implemented in all residential aged care units (RACUs). These guidelines promote “… a positive and open attitude towards death and dying [through discourses with the] aged care team, residents and family members” to enable care planning as a dying process to be implemented (Australian Government Department of Health and Ageing, 2004, p. 3). The palliative care approach provides a flexible individual plan of care identifying the wishes of the resident, family and significant others, which is achievable within the context of ‘end-of-life’ care and the quality care framework of Palliative Care Australia (Phillips et al., 2006).
Palliative Care Australia’s Standards and Quality Committee revised the National Palliative Care Strategy of 1999 (funded by the Australian government [DoHA]—Objective 2.1) to align consumer expectations of quality care with the government’s Guidelines for a Palliative Approach in Residential Aged Care (Australian Government Department of Health and Ageing, 2004). To support the adoption of individualised care planning for residents who are dying in aged care units, educational programs were written, such as the Palliative Care Quality Resource Guide: A Toolkit. This toolkit was designed to assist health care providers/services to utilise the National Palliative Standards supporting improved clinical and service quality, in the delivery of end of life care in the residential setting (Palliative Care Australia, 2005).
A further initiative of the Australian government was to allocate funding to promote the Program of Experience in the Palliative Approach (PEPA). This program acknowledges expert palliative care programs as useful for assisting RACUs to adopt a palliative approach, aiming to provide primary health care practitioners with the knowledge and specialist expertise that is needed to practice individualised care. Through this program, ongoing relationships evolved between specialist units and RACUs facilitating ongoing service development and potential to ensure continuing compliance with government guidelines. An outcome of the educational partnerships informs accreditation agencies of the compliance with government guidelines (Allen et al., 2007).
Why adopt a palliative approach?
The need for a palliative approach centres on the increasingly complex care needs of residents entering RACUs. This has required a rethinking of the ritualised care practices that have characterised aged care nursing in RACUs. The intent is for end of life and palliative care to be included in the planned trajectory of care involving a multi-disciplinary team approach (Australian Government Department of Health and Ageing, 2004, Phillips et al., 2008). It is management’s responsibility to ensure that services provided within their RACU comply with contemporary nursing practice that is reflective of best practice. To motivate staff to enhance their practice, skills and service delivery, staff require expertise to work and be involved in the dialogue to make decisions that will facilitate change (Phillips et al., 2008). Yalden (2007) highlights the silent voices of nurses in discourses relating to dying and death in RACUs. She details the difficulties in providing a palliative approach for residents of aged care units, because organizations require individualised educational programs for their staff, to facilitate the practice change required. Nurses who acquire knowledge and understanding through educational programs obtain skills that relate to practice which, in the concept of a palliative approach, include an individualised plan of care to optimise the wellbeing of dying patients (Yalden, 2007).
Tentative recommendations
The wider study has yet to be completed, however, from this brief discussion it is fitting that some tentative recommendations be offered regarding practice, policy and further research. It is clear from this historical overview that care of the dying has developed as a sophisticated area of healthcare. However, residential aged care services are still working to catch up with these developments.
Accessing professional development programs through workshops and seminars enhances knowledge and skills ensuring currency of nursing practice. Developing partnerships with expert professionals (specialist palliative care units) is another option available to nursing staff of RACUs to acquire knowledge in a supportive environment (Allen et al., 2007). It could be argued that without development of supportive partnerships between palliative and aged care, ritualised physical nursing care will continue to be delivered to residents of RACU who are dying. In examining the policies of residential aged care units, O’Connor (2004) demonstrates the importance of research being conducted in order to promote ‘best practice’. The current interest in conducting research in residential aged care settings will advance delivery of care in the modern context. It is possible to link the delivery of nursing care to the Guidelines for a Palliative Approach in Residential Aged Care (Australian Government Department of Health and Ageing, 2004, pp. 5–14) to provide a framework by which adherence and anomalies in care delivery can be evaluated (Allen, submitted for publication) ensuring that policies and procedures reflect ‘best practice’.
Conclusion
Through a scholarly discussion of the history of the development of palliative care internationally and within Australia, this paper has considered how caring for the dying progressed to increasing importance contemporary society. However, with the increase in repute, care of the dying has largely been ignored in residential aged care facilities where death is common place. The guidelines published by the Australian government facilitate knowledge and understanding in the modern context and address the issues of end-of-life care to residents, family members, and significant others assisting in the provision of adequate care.
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PII: S1322-7696(08)00048-6
doi:10.1016/j.colegn.2008.09.001
© 2008 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
