Proactive palliative care nurse specialist review compared to usual care, in residential care residents who are identified as being high risk of clinically significant health and functional decline.

Participants in the intervention group will undergo a structured assessment from a palliative care nurse specialist (PCNS). This assessment will take place in a face to face consultation and occur at the participants facility of residence. The participant, and their next of kin if appropriate, will attend the consultation, which will take approximately two hours to complete. Each participant will receive a single consultation. The PCNS will also review available medical and aged residential care (ARC) facility documentation as well as the current medication list to identify advance care planning issues, potential medication concerns or issues of polypharmacy. Based on the findings of that initial assessment and identified patient and family goals of care, an individualized care plan will be formulated for each participant. The plan of care will be formulated in conjunction with the patient/family, aged residential facility caregiver(s), general practitioner, and appropriate hospice interdisciplinary team member(s). Each plan of care will address management of suffering in the physical, emotional, relational, and spiritual domains, and attempt to align documented treatment preferences and medical/nursing care with identified goals of care. Outcomes will be measured at 1 month, 3 months and 6 months post consultation. This will allow investigators to monitor adherence to the plan of care.