Background Providing palliative care to frail older people in the last years of life is challenging. Increasingly this is becoming a focus of Community Matrons (CM) work. Effective communication between CMs and frail older people is vital, ensuring that palliative care needs are identified, responded to and met; a key requisite of the End of Life Care Strategy (DOH 2008).

Aim To explore interactions between CMs and frail older people towards the last year of life.

Study design A prospective, longitudinal case study design, using ethnographic data collection methods. Ten participants aged 75 years and over, receiving care from a CM, were recruited. Participants followed up approximately monthly for 6 months or until death. In total, 49 interviews were conducted with older people; 49 CM visits were observed. Medical documents were reviewed for 10 participants. Data were audio-recorded and transcribed verbatim. Analysis involved theme identification, with cross case comparison.

Findings A feature of the interaction between the older person and CM was ‘being at cross purposes’. This occurred when: the older person's concerns were discussed; changes were proposed to their routine; end of life conversations were initiated; role expectations differed. The outcome of these interactions led to the older person's concerns not being identified, and at times a lack of trust. These interactions typically occurred during transitions in health status.

Discussion How care is organised contributes to CMs and older people unintentionally being at cross purposes. CMs work is framed by a policy of Risk and Clinical Assessment, which can be at odds with a palliative approach. Assumptions underpinning the label of frailty, and the impact of transition on the older person, compound this further. Commissioners of community services for frail older people need to consider these competing demands so that CMs can engage more effectively in palliative care provision.