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A pilot of a pathway for individualised care of the frail elderly at the end of life
  1. Becky Hirst1,
  2. Christopher North2 and
  3. Janet Owen3
  1. 1Barnsley Hospice, Barnsley, UK
  2. 2Hillbrow Surgery, Barnsley, UK
  3. 3CSD Barnsley, Barnsley, UK


Introduction Palliative care has traditionally focused on those with a cancer diagnosis. For the frail elderly end of life care needs are often not identified or addressed, resulting in inappropriate admissions to hospital when they are dying. This pilot demonstrated that many frail elderly people nearing the end of their lives can be identified and by documenting preferences it is possible to promote quality of life and a dignified death in a person's chosen place.

Aim To improve End of Life Care across Barnsley and increase documentation of personal preferences for care.

Method Care homes covered by two general practices were involved. Residents were assessed using the Gold Standards Prognostic Indicator Guidance and “The Surprise Question”. Once identified preferences were recorded using the Preferred Priorities of Care Document (PPC), information was shared with Out of Hours care providers and care plans and simple pre-emptive prescribing put in place.

Results 43 patients were identified as potentially being in the last year of life, had a PPC and a care plan in place. During the first 6 months of this pilot, 10 of the 12 deaths which occurred were in the patients' preferred place. Anecdotally, improvement in information sharing between professionals increased confidence of care home staff and quality of care, non-elective admissions and length of hospital stay reduced.

Conclusions Local ownership by and drive from the health and social care professionals involved were key to the success of this project. Pro-active recognition of frail elderly at the end of life enables planning focused around individual wants and needs. Staff, families and patients found discussions positive. Recognition of need improved quality of care for this population. Resources now need to be identified in order to roll this initiative out across the locality.

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