There’s a conversation happening in aged care that nobody wants to have.

We talk about dignity. We frame it in care plans, quality standards, accreditation submissions. The Royal Commission handed down 148 recommendations, and running through virtually all of them was the same thread: older Australians deserve to be treated as human beings, not tasks on a workflow. Compassionate, respectful, individualised care. A good death. Those were the words used.

And yet.

Every day, in residential aged care facilities across Australia, a resident deteriorates. The clinical team identifies they are entering the last days or weeks of life. A palliative care flag goes up. The goal of care shifts, officially, to comfort. And then someone calls for a hoist.

Because the mattress needs to be changed.

The protocol we inherited

For decades, the standard approach to pressure injury prevention in aged care has been two-hourly repositioning, around the clock, seven days a week. The evidence for this practice is, to put it generously, thin. And it is getting thinner.

A 2019 Australian study published in the Journal of Bioethical Inquiry found that despite 91% of residents being repositioned on this schedule, 34% still died with one or more pressure ulcers. The intervention didn’t reliably prevent the outcome it was designed to prevent, and it continued right up until death regardless.[1] The same researchers asked a question that should have stopped the sector in its tracks: is two-hourly repositioning of a dying person patient safety, or is it elder abuse?[1]

That’s a confronting question. It was meant to be.

More recently, a NIH-funded cluster randomised controlled trial (the TEAM-UP study, published in Advances in Skin and Wound Care in 2022) tested three repositioning intervals across 992 nursing home residents: every two hours, every three hours, and every four hours.[2] The result was the same across all three arms. Zero new pressure injuries developed during the intervention period, compared to a 5.24% incidence at baseline. Not fewer injuries. Zero.[2]

There is a finding buried inside that result worth pausing on: staff compliance with the four-hourly schedule was 95%. Compliance with two-hourly repositioning was 80%.[2] The protocol that causes the least disruption to residents is also the one staff can actually follow.

The two-hourly protocol has governed aged care practice for sixty years. It was based on observations from 1962 and has persisted largely through inertia, risk aversion, and documentation culture rather than clinical logic.[2]

“Is two-hourly repositioning of a dying person patient safety, or is it elder abuse?”

What the pressure injuries actually tell us

Before dismissing that 34% figure as a care failure, consider what the evidence says about pressure injuries at the end of life, because the picture is more complex than the protocol acknowledges.

A significant proportion of pressure injuries in dying residents are now understood to be physiologically unavoidable. The wound care literature describes these as Kennedy Terminal Ulcers or, more precisely, as manifestations of skin failure: the same multisystem failure that affects the heart, kidneys and lungs in the dying process.[3,4] As the body shunts blood and nutrients away from peripheral tissue to vital organs, skin over bony prominences becomes ischaemic. Pressure-relieving interventions that would ordinarily prevent injury simply fail, because the tissue can no longer respond.[3]

Clinical photograph of a Kennedy Terminal Ulcer on a patient's heel
A Kennedy Terminal Ulcer diagnosed in a home care patient. These wounds develop rapidly in the final hours and days of life as a result of multisystem physiological failure, not inadequate care. They are a manifestation of dying, not a failure of nursing practice. Image: clinical case documentation.

These wounds are not the result of poor nursing care. They are the result of dying.[4]

This matters enormously for how we interpret that 34% figure, and for what we ask clinical staff to do in response to it. If a meaningful proportion of end-of-life pressure injuries are unavoidable regardless of repositioning frequency, the clinical question shifts. It is no longer simply how do we prevent this. It becomes: are we causing distress in pursuit of an outcome we cannot achieve?[1,4]

That is a question the two-hourly protocol has never been required to answer.

The mattress changeover nobody talks about

Layered on top of this is a practice so routine it rarely gets examined: when a resident’s condition deteriorates significantly, the standard response is to upgrade their pressure care surface. Out comes the foam mattress. In goes the alternating air mattress.

On paper, this is sound clinical thinking. A dynamic alternating surface offloads pressure continuously. For a resident with intact skin, meaningful life expectancy and good tolerance for handling, it is a reasonable intervention.

But what about the mattress that resident has been lying on for the past eighteen months? A standard foam surface body-mapped by a 90-kilogram resident over that period, compressed, conformed, never replaced, is not providing therapeutic pressure redistribution. That is a fair clinical challenge, and it points to a procurement decision that is rarely framed as a clinical one. Whether a pressure care surface maintains its therapeutic properties across the full duration of a resident’s stay is not a purchasing question. It is a clinical governance question, and most facilities have not asked it.

Set that aside for a moment, and consider what the changeover itself requires.

The resident is hoisted clear of the bed. The old mattress is stripped out. The new system is set up, inflated, checked and calibrated. The resident is lowered back down. From start to finish, this process disturbs a dying person, someone who under the Aged Care Quality and Safety Commission’s own end-of-life care guidance should be experiencing minimal handling, a calm environment, and freedom from procedural distress.[5] The Commission is explicit: in the last days of life, the priority is maintaining comfort and dignity, and managing distress.[5]

A mattress changeover on a resident in their final 48 to 72 hours of life is a procedural intervention that burdens a dying person without a reliably achievable clinical benefit. That is not opinion. It follows directly from the evidence on unavoidable skin failure[3,4] and from the clinical framework the sector has said it subscribes to.[5,6]

There is an alternative. A surface that can transition from static pressure redistribution to active alternating care at the bedside, without a changeover, without a hoist, without moving the resident at all, removes the intervention entirely. The goal of care changes. The surface responds. The resident stays where they are.

That technology exists.

The gap between what we say and what we do

The Royal Commission found that too few people in residential aged care receive evidence-based end-of-life care, and instead experience unnecessary pain or indignity in their final days, weeks and months.[6] It found that fragmented palliative care creates unnecessary distress for dying residents and their families.[6] The Aged Care Quality and Safety Commission has since codified end-of-life care as a core obligation under the strengthened Quality Standards.[5] Not an aspiration. A requirement.

That was 2021. The Standards were strengthened in 2024.

We are still defaulting to a repositioning protocol built on sixty-year-old data.[2] We are still designing pressure care pathways that require a dying person to be lifted out of their bed. We are still making procurement decisions based on cost-per-bed rather than clinical outcomes across the full duration of a resident’s stay.

The problem is not intention. Nurses working in residential aged care carry an enormous load, largely without recognition, without sufficient resourcing, and without the clinical infrastructure to practise the way they know they should.[7] Australian research has found that nurses frequently cannot provide the end-of-life care their residents need because they lack the equipment, the staffing and the support to do so.[7] In some facilities, residents in pain are transferred to hospital at end of life because the facility cannot manage their symptoms on site.[7]

The systems and equipment decisions made upstream, in procurement committees and finance discussions, constrain what is clinically possible at the bedside. A nurse who understands palliative care principles is still bound by what is in the equipment room.

Asking a different question

The question the sector has been asking for sixty years is: how often do we turn this resident, and what do we put them on when they deteriorate?

The better question is: why are we still treating those as separate decisions?

The TEAM-UP data points clearly to the surface beneath the resident as the primary variable. When the surface is doing its job properly, the turning interval can be extended without compromising outcomes, and staff can actually comply with the protocol rather than document compliance they could not achieve.[2,8]

A surface that carries a resident from admission through to the end of life, that redistributes pressure without two-hourly turning and steps up its clinical function without a changeover when deterioration occurs, does not just simplify a care pathway. It removes an ethical conflict the sector has been quietly managing for decades.

The Royal Commission was clear. Older Australians are entitled to a good death. Dignity and comfort in the final days of life are not aspirational extras, they are baseline obligations.[6] The care a person receives at the end of their life should be shaped by their wishes and their comfort, not by the equipment in the room, the staffing ratios on the floor, or a repositioning schedule derived from a study conducted before colour television existed.

Somewhere between that principle and the moment a hoist frame rolls into a dying person’s room, something has gone wrong.

It is worth asking, honestly, where in your facility that gap exists, and what would need to change to close it.

A carer holding the hand of an elderly man in a hospital bed, who is smiling
Presence, not procedure. The evidence is clear that what matters most at end of life is comfort, connection, and the absence of unnecessary intervention. A care environment built around that principle looks very different from the one most residential aged care facilities currently operate.