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Those working in acute medicine frequently treat older care home residents who are dying from chronic incurable conditions. These patients are often transferred as an emergency to the acute hospital setting, to receive sometimes formulaic and futile intervention at the end of their life. Commonly such intervention has no effect on eventual outcome but can often be unpleasant and distressing for the patient, their family and the medical team. In most of these situations, open communication, advanced care planning and adequate resources could enable the provision of end-of-life care within the care home, and so prevent unnecessary and undesirable hospitalisation at the end of life.
Globally, we are witnessing a changing demographic with population ageing seen throughout the world. In addition to this shifting demographic, we observe that our ageing populations are more often dying from chronic cardiovascular and respiratory pathology, combined with the presence of dementia and frailty.1 These frail older people with multi-system pathology and cognitive impairment exhibit an illness trajectory described as “prolonged dwindling”.2 Their decline towards death can be protracted, variable and difficult to predict. A steadily increasing proportion of these frail older people are living in residential and nursing homes. Care home residents often consider these institutions as “home” and have expressed a wish for their terminal care to occur there.3 Despite the unpredictability of the terminal trajectory in frail older patients, in certain groups the average life expectancy at the time of admission to a nursing home can be as short as 7 months only.4 Professionals involved in caring for this population should be looking to actively manage this end-of-life phase.
An expert physician panel has suggested that nearly half of care home to hospital transfers may be inappropriate.5 Why then is the dying care home resident not party to the benefits of actively managing the dying process within the nursing home? Reasons include frequent, often futile, hospitalisation, a lack of advanced care planning, poor physician and nursing back up, limited contact with specialist palliative care teams, and widespread uncertainty and lack of training among care home staff.6–9 Poor documentation at hospital discharge neglects to mention Do Not Attempt Resuscitation Orders, and primary care cover for nursing homes, both day-to-day and out-of-hours, can be patchy and varies widely between areas. As a result it is often the junior and untrained carer who is left with the decision of whether or not to hospitalise a dying care home resident.
The Gold Standards Framework in Care Homes (GSFCH) programme is a comprehensive UK-based national scheme undertaken with the goal of enhancing end-of-life care in care homes.10 It aims to improve the quality of care for older care home residents approaching the end of life and to reduce inappropriate hospital admission in the terminal stages of life. This is achieved through enhanced collaboration between care homes, primary care teams and specialist palliative care teams, enabling death within the care home setting. Impact analysis of phase 2 of the GSFCH programme indicated quality improvements in professional collaboration, proactive planning, crisis admission aversion, and better involvement of patient’s relatives. In addition, there was a potential cost saving because of reduced numbers of crisis hospital admissions and decreased hospital deaths.
Despite these promising initial data, such a scheme requires careful local implementation to manage local resources and ensure involvement from all relevant stakeholders. Geriatricians working between the acute hospital site and community-based care homes would be perfectly placed to effectively implement programmes such as the GSFCH, working together with primary and palliative care. Their expertise in general palliative care for older people, familiarity with difficult prognostication in frail individuals, and experience in instigating appropriate ceilings of care equips them to initiate and run programmes such as GSFCH. Proactive management consisting of early discussions about end-of-life preferences, clarification of patient and family expectations, access to specialist palliative care services, and careful contingency planning should be routinely considered at care home admission and reviewed regularly thereafter.
There exists a need for a deeper understanding of the most effective ways to deliver quality end-of-life care during the last 6–9 months of life to this numerically considerable, heterogeneous and vulnerable group of patients. More training, better collaboration and innovative programme implementation will improve the care provided to our increasing care home population. This should stop terminally ill older patients being sent to emergency departments at 3 am to receive formulaic and futile interventions.
Competing interests: None.
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