Worsening disability in older people: a trigger for palliative care

In a linked paper reporting a 15 year observational study, Gill and colleagues (doi:10.1136/bmj.h2361) highlight a strong association between admission to hospital and worsening disability in older adults.1 The authors suggest that hospital admission itself may be an important risk factor for increasing dependency in four activities of daily living (bathing, dressing, walking, and transferring) and adverse outcomes. About half of their study cohort had persistent or progressive disability and substantial care needs. These people also had a higher risk of dying than others in the cohort, especially when their functional ability declined rapidly. The authors’ main recommendation is important: that older people admitted to hospital with substantial disability should be considered for palliative care for control of symptoms, care planning, and increased support with personal care needs. How can this be done consistently?

It is known that older people are increasingly likely to have unplanned hospital admissions as their health deteriorates in the last year of life and that this happens for complex reasons, including age, socioeconomic deprivation, and multimorbidity.2 3 4 The risk of readmission due to multifactorial increased vulnerability is highest in the first few days after discharge but decreases exponentially over the next 30 days to the same level as that of the non-hospitalised population.5

Much effort continues to go into finding more effective ways of preventing the index admissions, along with timely discharge planning that helps people to return home with the care and support they need to prevent readmission.4 It may therefore be too simplistic to attribute deteriorating functional status solely to the effects of hospital admission. The impact of progressive multimorbidity and frailty also needs to be considered.

It is not surprising that older people with frailty and their carers struggle to manage at home when they are faced with sudden changes in health such as infection, particularly if these trigger an episode of acute confusion or a fall.6 Effective, holistic assessment of older people on admission and well established, multidisciplinary interventions that reduce the disabling consequences of a hospital stay are essential.7 8

A key point raised by Gill and colleagues is the need for a trajectory of functional decline in older patients to be identified and responded to, particularly when such patients deteriorate quickly over a relatively short period. Maintaining independence, being able to avoid institutional care if possible, and retaining a “sense of self” are of central importance to quality of life for older people who may be in their last year of life.9 A major goal for the current moves towards integration of health and social care in the United Kingdom and internationally is for multidisciplinary teams to be dealing with the personal goals and holistic care needs of older patients and their families at the same time as reviewing current and future treatment of underlying illnesses.10

What really matters most is systematic, proactive identification of people with deteriorating health who are at risk of going into hospital and dying there after a variable period of treatment and investigation that may or may not align with their personal goals. There has been a helpful progressive shift away from using mortality risk tools to identify patients for palliative care assessment towards tools more suitable for primary and secondary care that are based on readily identifiable indicators of deteriorating health due to one or more advanced illnesses (see box on bmj.com, also see www.spict.org.uk/the-spict/). Poor performance status and increasing dependence on others for help with personal care are highlighted in several of these tools.11

Earlier identification of older patients at risk of deteriorating must become routine clinical practice in hospitals and primary care. Identification should trigger conversations about what patients know about their health problems, what they are expecting, and what is important to them. Finding out about people’s goals helps patients, families, and health professionals to talk about possible treatment and care options aligned with those goals and to make individualised plans for current and future care. Some people will choose to make an advance care plan, nominating a legally appointed healthcare proxy and/or specifying treatments they would refuse if their health were to deteriorate and they lacked decision making capacity. All patients at risk of deteriorating, and their families, should be invited to discuss the benefits of anticipatory care planning, which can include their general and specific goals and an agreed emergency care plan should their health, functional ability, or care needs change suddenly.

Effective systems to record and share advance and anticipatory care plans for people at risk are important, along with more responsive emergency care. NHS Scotland has an established, national electronic anticipatory care plan (Key Information Summary) accessible to primary care, secondary care, and emergency services, and similar systems are becoming increasingly common.

In England, funding has recently been allocated for an “enhanced service” so that general practitioners can identify the 2% of registered patients at greatest risk of hospital admission for proactive care planning, extra support from a named doctor, and rapid access to telephone advice from a member of the practice team.12 Such improvements will be effective only if clinicians in all settings start identifying patients of all ages who are at risk of deteriorating and dying using indicators that include increasing disability, and if conversations about future care planning become routine.