“Jonathan you have to come in. There’s been an incident with Brian* and the other residents and families are scared, I don’t know what to do!”.

*Names changed for privacy*

The panicked voice on the other end was an aged care nurse whom I’d worked with closely and whose clinical judgment I respected and relied on consistently.

I quickly left what I was doing and headed to the facility.

She was talking about Brian, an 85year old man who was diagnosed with dementia a number of years previously and whose physical function had declined, requiring him to enter a high care aged care facility.

Brian had become my patient a few months before but his behaviour had changed and he’d become increasingly agitated, unruly and aggressive towards the staff and other residents.

Our tests didn’t show anything reversible but meanwhile, his behaviour was becoming unmanageable.

I had sought specialist advice from both my Geriatric and Psychiatric colleagues, but nothing appeared to be driving his behaviour that we could definitely intervene with.

We had countless multi-disciplinary meetings with Brian’s family, the nursing and care staff, the Palliative Care and Seniors Mental Health team and myself to help develop a plan that would provide Brian with a good quality of life but also keep him and the other residents and staff safe.

We focussed on Brian’s loves first — music, nature and family and then treated his pain with a low but regular dose of opioids and paracetamol. He responded well and if there were any issues, his daughter and son would return to help calm and soothe him.

This worked well for a few months before one day, his behaviour acutely escalated, requiring him to be admitted to hospital for the safety of others and himself.

As I sat with his daughter and reflected with Brian sedated and sleeping in front of us, she said “Thank you, this isn’t ideal at all. He wouldn’t have never wanted any of this, but what do we do?”.

We both sat in a peaceful helplessness knowing that we had made the right decision in the setting of great difficulty. Although the hospital wasn’t an ideal place to be, Brian’s family didn’t want him transferred to a Psychogeriatric unit in the city and he was too frail to be an inpatient in our hospital’s locked mental health unit.

Brian was transferred back to the residential aged care facility after both the Geriatric and Psychiatry team changed and optimised his medication. Brian lived for another 3 weeks before dying peacefully, with the nursing and care staff giving him beautiful palliative care.

The hope that I see

Like every noble pursuit in life, it is when we are challenged and pushed outside our comfort zone, that we learn the most.

Medicine is no different.

Brian was one of the most challenging patients that I have encountered in my clinical career. This is because he taught me about the balance between providing good palliative care, that is maximising his quality of life in the setting of his declining physical and mental state and keeping him safe.

Brian taught me more than how to manage difficult behaviours and psychological symptoms in the setting of dementia but about how families, aged care facilities and their professional care providers can work together to relieve suffering and provide patients with a good quality of life in their last years, months and days.

Whilst I personally felt that I was failing Brian and his family, it was to my surprise that his daughter and son, personally thanked me after his death for my dedication to his care.

That one thing deeply changed me.

It showed me that aged care isn’t about the glamour and the restorative wonder of medicine but about celebrating the full and interesting lives that my patients had led, recognising their strength and courage to have lived through difficult times and providing them with good quality palliative care until the end of their days.

I have hope in Aged Care because I have seen what it means to truly “care”.

When families are engaged and open and when aged care facilities truly desire quality of life and patient and family satisfaction as their main driver for success and when care professionals display excellence and passion, there you find an older person who is aging well in care.

The hope and desired change for the aged care sector

With the Royal Commission into Aged Care being announced, those of us who are devoted to the practice of aged care, are optimistic that this will bring forth meaningful change.

I have hope that despite reports of GP’s deserting aged care and the countless reports and senate committees in the sector, that our aged care sector will provide excellent care that is unmatched.

Aged care is not J-O-B to simply turn up and “wing it” and for those who desire to simply make a paycheck regardless of how you feel towards the elderly, caring is not for you.

With regards to focussing on profit by restricting the levels of care and dictating and rationing what is a basic human right, my hope is that what has been kept in the dark and in secret will be exposed in the broad light of truth and justice will be served.

The most valuable players in aged care

Aged care leadership begins at both the coalface and at the top of the organisation.

Read: How to be a standout health professional in the aged care landscape

If we want meaningful change in aged care, we need to look at the end goal behind and those who are responsible for delivering care.

If our goal is compassionate, person-centered care with specialist skills in safety, comfort and the wellbeing of our aged care population, then the most valuable players in aged care are our carers.

Carers deserve to be carefully selected, well remunerated, trained and educated continually in dementia and palliative care and most importantly their health and wellbeing ensured.

One of the greatest joy in my aged and palliative care practice is educating carers and nurses because the most valuable ones are hungry!

They want to know more because they want to deliver better quality and evidence-based care and are driven to excellence.

If you want a healthy aged care sector, invest not in the image of the organisation but those at the coal face of care, that will bring lasting change.

This is my hope for aged care in Australia.

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Live intentionally.

Love relentlessly.

Enjoy your health and get smarter every day!

Dr. Jonathan Ramachenderan
@thehealthyGP