96 years old, and I’m coming to kick your ass!

The other day, following a particularly frustrating incident I posted this on Facebook:

No. No. No.
This 96 year old man should not have been transferred from the nursing home to die in the midst of an emergency department.
If anyone does this to me when I am 96 I will sign myself out, drag myself home and Kung-Fu kick your ass.

Now up front, let me say that I have the greatest regard for the aged care specialty, and nursing homes in particular. My venting was related to this particular presentation (of which I cannot go into the details without potentially identifying the case), and its similarity to Betty’s death.

The following responses make such compelling reading that I have printed them below.
I will let your read on without further comment, other to say once your have had your fill,  please come back and click on:  this link and send an email to the Australian Prime Minister.
Thank-you to all for your excellent and thought-provoking comments.

Mars: When will this ever stop!!!….96 why?. leaves me with a heavy heart.

Beccy: We had one of those the other day…. Green lighted, NFR and DOA…. Beats me why nursing homes do this to ED’s

Dee: Ditto …. because ED’s do death & dying so well & we need all the experience we can get. So sad for that poor man – & his family.

Kim: My family has been WARNED!!!!!!! They won’t have to transfer me from a nursing home because I won’t BE in a nursing home. EVER. As far as I am concerned they are Elderly Storage Facilities. <shudder>

Nicole: Sad thing is it always happens.

Sandra: did his family and he request full code? I’ve seen it. In that case, the patient would be sent to the ER. If not, shame, shame on the nursing home….

Kathy: What were the staff and family thinking let them be at peace

Kristy: Management make staff bow to all family demands at my nursing home. We hate it, but sometimes things like this happen.

Marel: ‎96 is called dying from old age! Society just doesnt accept this anymore. You have to die of something…Oh he died of a heart attack at 101! I want my final diagnoses to be death from old age…naturally!

Susan: We get it all the time too……catheter came out, skin tear, had a fall (didn’t hit head), chesty cough, you name it! What happened to RN’s in these facilities? We had a 96 year old who arrested and since we did not have an NFR for him we resussed him. His NFR arrived later that afternoon…….he died a couple of weeks later at home where he should have been the first time.

Karen: Did he need care that could not have been given in the home??? Did he need pain relief?? I think nursing homes need better support. Drs or nurse practitioners who can see patients in the middle of the night or day and manage them thus saving them being transferred unnecessarily. And some education for staff may help. Some places are left with ENs overnight. Or maybe they rely on casuals who dont know the residents. The whole health system is grossly under-resourced not just ED. But that isnt new news.

Peter: Ian.. one of the most funny and yet piquant statements you’ve made…

Kathy: My parents Mum 95 and Dad 94 have told me to make sure no heroics are used . They have had a good life. Have both lived with me for last 5 years . Mum has just gone to nursing , her dementia has just got too hard for home. It’s been lovely having them around so long. They had me when in their early 40′s. Now they just want to go peacefully when the time comes…..

Cate: it happens way too often and is just a lose-lose situation all round. We’ve had “hospital-in-the-home” running successfully for years now, it’s about time we had “hospital-in-the-nursing-h​ome” where some acute intervention could be instituted if warranted, without the need for transfer, and the transition to “end of life” care would be seamless.

Joy: Agreed Karen,the nursing homes are not staffed well nor are they adequately funded for doctors to come in overnightThey need to fix nursing homes properly which would ease the hospitals and take care of our elderly properly

Angie: It’s very sad. My feeling is that with downgrading of skill mix in n/homes the staff that are often there don’t feel qualified or confident to make what could be end-of-life decisions. Rather than animosity towards aged care staff who are often AINs and doing their best within their knowledge and capacity we need to support aged care staff in their push for equity in pay, reasonable work loads, and safe skill mix. Well staffed / well educated / well supported aged care facilities is the only way to ensure our elderly community isn’t subjected to this sort of craziness.

Alison: Omg this happens way too often for my liking, how about respecting patients wishes!!! I’m sure they would be more at peace in familiar surrounding than in a small cubicle with a person swearing and cursing next door!!

Michaela: The issue is that people are not allowed to die. Families in aged care often feel guilty, and they think that by keeping their loved one alive, is letting them live. Nursing home GP’s won’t make the ‘palliative’ call until they are bloody cheyne stoking! Everyone is worried about litigation. I work casually in Aged Care as well as permanent Emerg. Often cannot get after hours locums. I won’t risk my registration in NOT sending someone who needs medical help, regardless of age. Very sad. I feel for that 96 year old.

Brent: The old Friday shuffle from acopic nurses in aged care joints. Isn’t this why we have in -reach services and palliative care teams? ( mind you a bit stupid to have the in reach running 9-5 Monday to Friday)

Michaela: I take offense to acopic nurses! Perhaps acopic aged care system and incompetent politicians would be more appropriate.

Melissa: Or worse.. Intubated and sent to CCU !

Fiona: The RN’s in these facilities are sometimes responsible for the oversight of 40 + residents, which is ridiculous and unsafe. What about Respecting Patient Choices programs, these are not limited to acute and perhaps more people in the acute settings could drive an initiative with Palliative care teams to work in conjunction with local nursing homes. I totally agree this should never happen and is wrong. I am thankful that my grandmother was “allowed” to die of respiratory failure in her nursing home Boandik Lodge in Mt Gambier, the staff were wonderful and she was 93, that is totally acceptable, there was no need for her to go into an acute setting to die of that. Old age and dignity in death need to be reinforced. Right care in the right place at the right time!

Hayley: yeh not fair hey…..noise, yelling gees, he should have been in his bed in some peace and quiet, poor bugger

Bobbie: That is so so sad, for everyone, to die in the hurly burly of the Emerg dept instead of at home (and that is what nursing homes are), i can understand if the family are insistant and can’t be dissuaded, but was this gentleman also consulted, we have had completely lucid 90 year old arrive in the Dept at the request of family members, who completely had their own wishes dire

Lynette-Netty: I’m a Pall Care nurse specialist temporarily moonlighting in Aged Care so I’d like to set the record straight. In the first instance advanced directives are not always provided on admission, and they should be mandatory. Most elderly people don’t want the heroics, it’s the family who force life prolonging interventions; they don’t want to let go. Even if resident’s wishes are documented & signed in regard to end of life management, the attending GPs WILL NOT WRITE PALLIATIVE DRUG ORDERS IN ADVANCE!! Why? Because they don’t trust the RNs; they have no confidence in our competence and are afraid the drugs (eg. narcotic analgesia, sedation) will be misused. They’re terrified of the “E” word, and that grieving families will instigate litigation. Putting all that aside, another issue is that these GPs are NOT ON CALL after hours, and if there’s no drug orders what do U do? Ring a Locum? Yeah right, they take hours & hours to arrive and even then are reluctant to write in the drug chart because …1. they aren’t familiar with the resident and 2. they don’t want to step on the toes of the treating doctor. Getting the picture? Right…so here you have an aged person who’s blown a ventricle, is screaming in pain, they’re a lovely regal shade of purple and the sats are thru’ their boots. No morph, no midaz and no other way of keeping them comfortable except to ring 000. Or how about APO secondary to a long history of cardiac failure?? Some injectable Frusemide would be nice, but nooooo, we either watch while they panic and drown in their own secretions OR we ring for help. Cancer patients? Forget it..let them experience the excitement of a catastophic event. Don’t worry about the Midaz, just have the green towels ready!! But we’ll just let them suffer, they’re old after all and what does it matter.. they’ll soon be dead anyway!!!! I’d never worked in Aged Care until recently, I thought I could make a difference by delivering adequate end stage care in their own HOME environment and teaching others to do the same. Hah! So much for dignity, compassion and relief of suffering! Trust me, it’s not that aged care RNs are over the fence, developing Alzheimers and aren’t up to scratch with their practical skills….quite the opposite. Assessment skills have to be A1 because these people have multiple, chronic conditions and anything could (and does) happen. It’s to be expected. What’s needed is the co-operation of GPs to ensure we’re able to manage these events as they occur, not take up precious resources within the acute sector. It’s bullshit!! I’ve witnessed some hideous deaths that should never, ever have happened. ED doesn’t want the geriatrics and believe me, WE don’t want them in there dying on trollies over a 12 hr periord. If anyone can solve the problem, you’re a better nurse than I am Gunga Din. Gods know I’ve tried!!

Beccy: I don’t think we know enough about this story to pass judgement. We don’t know what he died of…

However there are times when people need to be transferred to A & E from Nursing Homes. One quick example I can think of as to why older people end up in A & E from Nursing homes is a coroner’s report I read recently about the fact that catheterisations NEED to be undertaken in a clinical hospital setting if any resistance is encountered in males, particularly those on warfarin and those prone to serious infections.

Another reason that nursing homes transfer is because of the fear of litigation. Despite age, if you are found to be negligent and not exercising duty of care, then as we all know your career could be over.

Fiona: Agreed but individually none of us make an impact. I work in a program that interfaces acute and community inclusive of residential facilities, it can work, but it is hard work. Lynette from the sound of your expertise and experience you could be one such person who drives a change in healthcare provision and how it is provided. I wish there were more people who wanted to be involved. We are now seeing the results of our work and another program is running by a private organisation along the lines of the Community Matron model in the west of Adelaide and is also having success in reducing inappropriate hospital admissions also. It is about pulling in members of the health care team and community providers around each patient. There have been 60-70% reductions in ED admissions from the ICCOP program and obviously they only look at frequent flyers to ED but it has to begin somewhere to drive an overall change

Von: Well done Lynette !! I have worked in aged care for over 10 years and there are times when unfortunately the elderly do have to be sent to A & E for what is deemed un-necessary, but unfortunately there is an aged care crisis particularly in country or rural areas where many places are under staffed, under paid thus not attractive places to work for many Rn’s……..So what are those not qualified to be making life saving or life threatening decisions to do ????? Get crucified for not working within their scope of practice. My point is the state of aged care is a political problem rather than the staff who actually work there.

Lesley: Happens all the time,its awful.Poor old buggars sent out of their beds at night for something ridiculous that isnt going to be treated anyway.Let them stay at home and go peacefully.We had one recently,a 100 year old woman in a usually vegetative state with advanced dementia.Nursing home sent her to ED at 8pm on a Friday night because she had bleeding from her ear.Can just see it now,our reg ringing an on call neurosurgeon and explaining to him we have a 100 year old with a GCS 0f 6 (usual state) requiring neurosurgery.Sheesh…..

Lesley: And it turned out it was just a drop of blood from a small scratch.Would have been helpfull if the staff had actually checked that first before moving the poor woman,tying up an ED bed and staff for several hours and wasting 2 trips in an ambulance….

And people wonder why our hospital system is stuffed and we have long waiting times???…….

Robert: Once you extract the justified venom in Lynette-Netty’s post, you see she is spot on. If you are an ED RN, and some Geri comes (is sloughed) from a nursing home to die in your department, quit your grizzling about an indignities death and who is to blame, and take responsibility for your nursing license, and make it a dignified end. Bitching about aged care RNs us a cheap shot , by a bunch of A type FIGJAMs too chicken, or hopeless to WANT to make a difference. Walk a day or a night in an aged care nurse’s shoes, before you try to comment on their skills. Ask them how many times they didn’t call that ambulance, before you complain about the one or two times they did. This was sad for the old bloke, but for gods sake deal with what comes in through those doors and quit your bitching

Cath: Amen

Vicki: funny how quick this profession judges others

Lynette-Netty: So many condemnatory comments relating to “acopia” of RNs in Aged Care. I’m just a bit offended and completely over this ignorant/arrogant assumption that aged care nurses are decrepit, under-skilled, clueless, inexperienced, unspecialised old farts who have chosen to live out their autumn days sitting on their flabby, cellulitic, incontinent arses hiding in an office doing ACFIs and functioning at a clinically sub-standard level of practice! Scuse me? I’m fed up with this apparently widespread notion (not the least of whom are the newer members the profession, in my experience) that we haven’t done our time in various specialties and have minimal or outdated knowledge/expertise. I had one little upstart from a private hospital ring to tell me a rezzi COULD be discharged back to the Facility IF I was confident enough to give Clexane!!! OH PLEASE! I object to being patronised and spoken down to in such a condescending fashion by smug, misinformed “colleagues” who consider themselves superior because they work in ICU, ED, theatre…whatever. Just for your interest, we’ve already DONE those hard yards, so get off the pedestal and deflate your craniums. Regardless of area, there are good and not so good nurses. Look at Nurse Academics…some may not have touched a patient in 20yrs, but hey, that doesn’t make them less valuable or worthy…we NEED them if the nursing profession is to grow and develop. I teach, I supervise, I mentor and I’m a damn efficient, caring & dedicated nurse like thousands of us over the age of 45. Oh, and by the way…very few Domicilliary Palliative Care Teams visit nursing homes, nor does RDNS because of the huge fee they demand. ROSS Teams can, but what a bloody long, drawn out referral process that is & by the time they arrive rigor mortis has long set in…like weeks ago! We RN’s in A.C. can do it…we just need support, it’s the GPs who need education!

Katie: its disgusting!! I work in aged care, its low care but still we only have one staff member looking after 30 demntia reasidents and one looking after the 75 without dementia. We never have an RN after 5pm or on weekends. And with the “ïf in doubt, ship em out” attitude it’ll never change unfortunately.

Linda: I saw this sort of thing happen too often when I was on placement in ED. It’s such an inappropriate place to die and an inappropriate place for the family to say farewell. These patients often end up with NFR orders but in my opinion don’t end up with the quality of care they require. I’m really glad you brought this up because I think there needs to be system wide rethink about how we can support the natural dying process without sending these people to ED.

Mona: When you’ve had to code a 103 year old because their family of leeches is living off their check, or a 90 something because the nurse at the skilled nursing facility said, “George always wanted everything possible done” when “George” is end stage everything, fetal position, contracted so badly they have to put an IV in the IJ because it’s the only vein you can reach, the code team breaks their bones to straighten their arms out enough to even get to the chest to begin compressions and tube feeding is spraying out of their mouth and from around their nasty, necrotic looking PEG tube….I’m going to have “DNR” tatooed on my chest when I turn 60!

Lynette-Netty: Apologies to everyone for my verbosity…it’s the frustration talking, sorry.

Danielle: Sad that death these days seems to be a medical event rather than just something that happens to all of us. Fighting between ourselves or finger pointing isnt ever going to get us anywhere.

Brent: I take offense offended posters. Have a think why such comments are made. I work as both a paramedic and an emergency nurse. 23 years I’ve watched the weekend turf game. I go to ACFs and find SOB patients lying flat on their back time and time again or left with their symptoms to the absolute last minute or sitting their in APO with a pari of nasal prongs or the best a cardiac arrest with a hudson mask on!

The only thing that should change betwen an acute hospital and an aged care facility/nursing home should be the postcode. Basic nursing skills are something every nurse should have, and I’m sick of having those on the same register as me who cannot assess a sick patient or manage illness beyond popping pills out the webster pack, emptying a catheter bag and directing a PCA to change a incontinence napppy. Preventiative nursing and pre-emptive care is vital to the well being of dependednt patients/ residents. Blaming governments totallly for a lack or professional testicles is wrong. Perhaps AHPRA or heaven forbid the ANF could grow a couple and stand up to these businesses behind nursing homes for once.

I am fortunate to attend many ACFs in my area and there are some who are absolutely wonderful, the dignity of life is respected, the urgency of illness is too and the nurses and carers there are first class. They don’t shy away from their responsibilities as Nurses and are sound and proud advocates for their well being.

Yes, inreach programs should be extended. GPs should actually remember what a sick person looks like premorbidly. Businesses should I agree to pay enough to recruit REAL nurses instead of the cheapest option. Families too need to be told the reality of aged care an pallitive care to help them accept the wishes and rights of their loved ones so we are dragging these poor souls away from a peaceful passing.

And I shouldnt get “Sorry, not my patient” when I ask why this patient is trying really hard to die with no one present.

Chris: problem is so many aged care carers are not trained in good palliation, cos the management does not want to spend the $ on training them, they can just call an ambo and let them and the A&E’s deal with it. or the families refuse to allow the resident to be NFR and insisit on full treatment, thus the nursing homes hands are tied and they have no choice but to transfer to A&E.. MORAL is TELL YOUR FAMILY AND DOCUMENT WHAT YOU WANT BEFORE YOU ARE CONSIDERED INFIRM AND DECISIONS ARE TAKEN FROM YOU..

Hugh: Yerp, death is the opposite from birth on the continuum of life. Quite normal, natural and inevitable. What’s not OK is that the dying aren’t always consulted in the decision making process and they’re kept alive or rescusitated when it’s known they will not enjoy any quality of life. Sooner or later the Grim Reaper claims us all, no one escapes. It’s also inhumane for doctors to allow these patients to suffer unnecessarily when they have the means at their disposal to prevent it. “Cure sometimes, Relieve often, Comfort always”! It’s something all health professionals need to remember.

Fiona: I don’t think it does anyone good to denigrate anyone in any profession. It is a system failure and the only way to address it is to escalate the problems. If anyone seriously wants to make change as a collaborative group you can. At the heart of all the politics, drama and bullshit though are human beings who have a right to have their basic care needs met again in the right place and at the right time.

Chris: EVERYONE who has posted thus far has pertinent comments, no one is wrong.. we all see the problem from different sides. pitty we cant get together and convince the government, aged care providers, educators, doctors in all walks of life, resident relatives, significant other and colatteral people involved..

Fiona: We can Chris and some of us are! Join the revolution to change the face of healthcare in any state you work. Put in an application for funding, work out your pilot project, target groups and get your demographics. It is hard work and thankless until three and a half years later you see some results. I have only been with my program for 5 months and it is amazing. Usually it means working with all the groups that nobody wants to or are marginalised – but the results speak for themselves. We can all be revolutionaries in changing the system if we believe in it enough.

Leanne: Lynnette -Netty is my new hero. Could not have put that better myself. Thank you for setting the record straight about the problems we face in many Aged Care Facilities. Getting people to understand the real crisis in Aged Care is difficult and we should all be working together as a profession [whatever field of nursing you work in] to address the issue.

Sue: Did the 96 year old man get seen by a doctor or did the ED nurses make the decision on how to care for him without any input from a doctor? I’m pretty sure that if a 96 year old patient in the hospital suddenly starts to deteriorate, the nurse looking after him contacts a doctor. Why do people think this doesn’t have to happen in aged care? The problem is getting a doctor, it’s hard enough during the day, let alone at night or on the weekend. If you CAN get on to someone, almost invariably the answer is ‘send them to hospital’. If a resident is deteriorating slowly, there’s time to get the doctor to see them and to get it documented that yes, death is likely approaching, and get medications ordered, or whatever is needed. It doesn’t always happen that way unfortunately – often the deterioration is quite sudden. It’s so depressing to read some of these comments, I just wish some acute care nurses really understood the difficulties of working in aged care. One RN is responsible for 30, 40, 50 or even more residents. At night there may not even be an RN on the premises, if there is they’ll be responsible for the whole facility – that could be 100 or more.

Sunny: I have to agree with Lynette and robert and a few others on here. + have a broad idea on many sides and have worked in a lot of areas in hospital nursing but am currently doing a bit of aged care as an rn and I have to say that unless u have walked a mile in another shoes you don’t really understand the trials specific to that area. I used to have some very poor ideas about aged care and I am here to say I was completely wrong. On a night shift I am in charge of over 80 residents (i do days and arvo’s too) and with very limited staying it is a tough job to do and most overtime hours away from my children go unpaid and unappreciated. Our big problem is no advance directives (sorry not gonna be the one who decides and pays for it) and families are not always encouraged to organise it either, then we have our very lovely well meaning drs who ask US what medication to give and then bulk at a reasonable dose of narcotic for those in the throes of end stage chronic disease…(yeah, like 5mg of morph is excessive my arse) but knowledge is power and I think multidisciplinary care meetings in aged care may help…certainly worked in hospital setting to get everyone on the same page…lets hope it improves before too long.

Sue: Sarah, I take your point about staff ‘panicking’ at times, and I think that does happen now and then. It seems to be when the resident has an unrealistic family who think their relative will never die, and if any medical problems at all do arise, it must be because the aged care staff didn’t notice something, or didn’t act on something, or didn’t send the resident to the hospital! It’s very very difficult to be the one there on the spot, with no support, no one to talk to about the situation, unable to get a doctor, and knowing what the family is like. I so wish each aged care facility had acess to a doctor who knows the residents (if the doctor doesn’t know the resident, they’re understandably reluctant to make any decisions at all especially over the phone), and who can come when needed. I think residents and their families have the right to timely access to a doctor without having to go to the hospital.

Colleen: lets not mention that nursing homes do not even have equipment such as subcut sets, catheters etc…..it is not that the staff are inadaquate- there simply are not the resources there to ensure a patient dies in comfort…im so tired of the denigration of nursing home RNs and staff……there are plenty of bad tales from all wards in all hospitals regarding staff ….stop the bagging……change things….be proactive- insist on nurse practitioners in the nursing home….insist on better ways and treatment for our dear old folks who deserve the best in care- advocate for the patients there who deserve a doctors presence in their last hours- even if it is to console a family…..21 or 91….this is someones dad…some ones mum……

Julie: How how how HOW does this happen so much. Extended Care planning my arse. So degrading and wrong.

Lisa: MAKES ME REALLY GLAD I WORK WHERE I DO (AGED CARE) ‘COZ THIS WOULD NEVER HAPPEN TO US….Its called “beginning with the end in mind”. We have a NFR/Do not transfer signed on admission (even our Rural Health/Public Beds), alongside the where and when emergency contact details; We have highly skilled RNs who specialise in Aged/Palliative Care; frequently consult with our local Palliative Care Team (who assist Doctors, Nurses and Family alike!); and 24 hr Telephone Consult with Dr available. (We do what we do very well!)

Lynette-Netty: Colleen, not all ACF’s are poorly equipped. Everything from syringe drivers, to suturing materials, to catheter packs, to s/c Intima devices are often readily available, but it’s not much help when some-one (aged 90) is dying post cerebral event, has just had a massive vomit and aspirated… and guess what? The suction doesn’t work!!! Fact, it happened! Care staff sobbing as they looked on helplessly “PLEASE do something, this is wrong, help her!” No orders, no doctor (Locum refused to drive the distance & was flat out), nothing to clear the airway, and not considered a 000 priority call. Shocking death 14hrs later. It could have been so very different…breaks my heart.

Sunny: Lisa that would be a dream in our facility…I have constantly brought these issues up in hopes of the situation changing and still nothing happens…so I just do the best I can with the resources I have and try to manage what I can within the facility and badger the drs til they get it…hopefully practise such as in your facillity will infect aged care as a whole to get better outcomes.

Lee: tell that to country nursing home staff, who have a habit of doing just that

Leanne: Absolutely……

Bobbie: Who is this Lynette Netty:, I’m an A&E nurse and I get frustrated when residents are sent to Emerg for simple tx that could be handled by clinicians in the nursing home, humane practice mandates that we alleviate suffering no matter the age of the patient or their resus status….. I get it, but Lynettes comments really struck a cord with me, not ashamed to say I actually teared up, you’ve given me a lot of food for thought and challenged a lot of my misconceptions, Thankyou…

Lisa: Hey Sunny Coaster (I used to live there!) a Palliative Care Referral is a good way to get around difficult doctors. Err, help them out I mean. I have suggested doctors to do the PEPA (pall care) training that our nurses do.

Lisa: ‎…..And doesn’t everyone have” GP Assist” or 1800DOCTOR? ….Anyone can ring this number and speak with a Doctor (via a nurse). Even on a night shift, when I the only RN for 90 residents – if something UNEXPECTED happened, I can ring this number, have a doctor call me back and get a phone order for something to keep him comfortable until morning. (We can start a syringe driver there and then, if needed – although that would usually be done by the pt’s regular doctor first thing in the morning, if they made it through the night. If I got a stat dose over the phone and it wasn’t sufficient, I could ring the GP Assist back minutes later if need be…..If I DIDN’T HAVE this service (Really, doesn’t everyone?) I think I would just TELEPHONE my local Emergency Department, get a phone order from a doctor there ?? ?

Lisa: ‎(And as for staffing levels – well, naturally everyone who is on stops what they are doing(2 others on) and comes to help me with this person-including witnessing orders and dealing with S8s)…we also have dect phones everyone carries on them and can transfer/receive calls. . . if another resident was could not be left immediately, for example.

Lisa: LYNETTE-NETTY keep campaigning for it coz it can happen. We had a fantastic GP whose spcialised in Gerontology did provide a prn “Order for Catastrophic Event” for a resident who was expected to bleed out also. Not a coincidence perhaps that he was an RN before he became a doctor! I stand by statement – Doctors should be PEPA trained also!

Lynette-Netty: Nope, doesn’t work like that where I come from. A Pall Care referral means the person in the ACF must have been declared “palliative” by the treating doctor. If you skirt around the GPs you’re up to your neck in the proverbial…!! End stage chronic, progressive conditions (and that includes ageing) OTHER than cancer, neuro diseases (eg. Motor Neurone) frequently do not fit their “criteria” (yep, fact). They feel the LMOs should be able to manage it, and they’d be right!! Funny you mention ringing the local ED for a phone order…I’ve done that too on many occasions without success. Appears if the resi is elderly, dying & in crisis it’s not an emergency. “Ring the GP in the morning” I’m told, with the additional advice “don’t send him in here…we’re already out the doors”. As if I want that for the resident anyway! Palliative management plans shouldn’t be left until something “unexpected” happens or they’re already “plucking”at the blankets and experiencing terminal delirium. Strategies need to be in place well in advance to cover all likely scenarios & aged cares nurses should be capable of following thru’ with the delivery. There is PEPA type programs for Drs, but they don’t think they need education & are offended when it’s suggested. The Govt “Guidelines for a Palliative Approach in Residential Aged Care” is all well & good in theory, but trying putting it into practice…epic FAIL!! If anyone wants a copy of this 259 page travesty go to www.health.gov.au/palliati​vecare