Table 1.

The six steps of the ‘PACE Steps to Success intervention’

Steps	Tools/materials	Content of the steps
1. Discussions as the end-of-life approaches	‘Looking and Thinking Ahead’ document	Advance care planning (ACP) discussions with residents and/or families are conducted to elicit wishes and preferences around end-of-life care. This communication process usually takes place in the context of an anticipated deterioration in the individual’s condition in the future, with attendant loss of capacity to make decisions and/or ability to communicate wishes to other. ACP discussions may either be planned or ‘opportunisitic’, meaning that it can be initiated when a resident brings up the subject voluntarily. As palliative care aims to improve the quality of the remaing life, these discussions should not be just about the very last few days, but also about living well during the last years of life.
2. Assessment, care planning, and review	‘Mapping Changes in Condition’ chart	Nurses and care assistants are ideally placed to identify the various clinical triggers that indicate that a frail older person may be entering the last phase of their life. The ‘Mapping Changes in Condition’ chart plots deterioration and improvement in a resident’s physical condition. The chart helps staff recognise changes over months. By completing this every month (and every week when a resident is in the last phase of his/her life) one can see a trajectory over time of how the resident has been.
3. Co-ordination of care	Palliative Care Register Monthly multidisciplinary palliative care review meetings	Using a Palliative Care Register, residents who are identified as expected to live less than six months are discussed in detail during monthly multidisciplinary review meetings. The register prompts staff about different aspects of care to be considered. A summary sheet of those residents with particular needs is completed and sent to health professionals (such as GPs) who were not able to be present in the meeting.
4. Delivery of high-quality care	‘Long Term Care Facility Pain Assessment and Management Tool’ ‘Geriatric Depression Scale’ (short version) or ‘Cornell Depression Scale for people with dementia’	The staff is educated concerning general principles of palliative care for frail older people including those with dementia, symptom control and complex communication skills. This step also involves the training of care staff to assess and manage the particular symptoms of pain and depression. Pain assessment is undertaken on all current residents in the facility and on admission of all new residents. Assessment is continued regularly if pain is not controlled and/or at a six-monthly review. Assessment of depression is undertaken if a resident is considered depressed, or following admission when a resident settled into the nursing home if mood appears low.
5. Care in the last days of life	Integrated care plan for the last days of life	Use of an integrated care plan for the last days of life to empower staff to provide high quality care to the dying resident and their family. The Last Days of Life checklist prompts and guides the care, ensuring that appropriate medication is available or unnessary medication is discontinued in anticipation of symptoms during the dying process.
6. Care after death	Monthly reflective de-briefings groups	Monthly reflective de-briefings groups to support staff following a death and encourage experiential learning.