Managing End of Life Needs of Frail, Older Adults in the Community: The Role of a Hospital-Based Community Outreach Team

Abstract

Background Our current healthcare systems are designed around periods of acute illness and are ill equipped to meet the needs of multimorbid and frail adults with worsening mobility, cognition and function. According to The Irish Longitudinal Study on Aging (TILDA), Ireland has a high proportion of hospital deaths, indicating inadequate community and home care supports. Recognizing patients who are likely to benefit from supportive and palliative approaches with a goal to die at home can be done using a combination of tools and based on advanced care planning discussions. Methods In 2021, our Department for Older Persons Services allocated a team consisting of a Registrar and Advanced Nurse Practitioner in Frailty to form an outreach service. Inpatients who appear nearing end of life who have expressed wishes to avoid further hospitalization and to die at home are identified during their admission. Home visits allow for a holistic assessment and family members are given the opportunity to ask questions. We provide education on end of life, trying to anticipate needs and often see patients and families through periods of deterioration until they stabilize again in a ‘new normal’ or begin the process of active dying. We communicate with Public Health Nurses, General Practitioners and the Community Palliative Care Team. Results Families and carers supporting loved ones who wish to avoid further hospitalization and die at home benefit from combined medical and nursing support & specialist expertise the team brings. Conclusion Addressing end of life for multimorbid patients living with severe frailty is a global challenge. Hospital admission is an ideal time to begin conversations regarding goals of care and initiate advanced care planning. The outreach team work together with hospital and community colleagues to the common goal of following patients’ wishes at end of life.