Clinical update

How nurses can deliver person-centred end of life care for older people living with frailty

New guidance from the British Geriatrics Society aims to support nurses to deliver high-quality, person-centred care

New guidance from the British Geriatrics Society aims to support nurses to deliver high-quality, person-centred care

Care planning in a hospice. Picture: Stephen Shepherd

Essential information

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves, according to the British Geriatrics Society (BGS) .

About 10% of people aged over 65 are living with frailty, rising to between a quarter and a half of those aged over 85. They are at risk of adverse outcomes such as dramatic changes in their physical and mental well-being, after even minor events,

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New guidance from the British Geriatrics Society aims to support nurses to deliver high-quality, person-centred care

Care planning: a nurse outlining options for a patient in a hospice

Care planning in a hospice. Picture: Stephen Shepherd

Essential information

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves, according to the British Geriatrics Society (BGS).

About 10% of people aged over 65 are living with frailty, rising to between a quarter and a half of those aged over 85. They are at risk of adverse outcomes such as dramatic changes in their physical and mental well-being, after even minor events, according to the BGS. They are also at risk of significant harm if health interventions are planned without their frailty being recognised.

What’s new?

Supporting nurses and other healthcare professionals to deliver high-quality, person-centred care for older people with frailty approaching the end of life is the aim of new BGS guidance.

Covering the final year of life for people living with frailty, the guidance addresses issues such as uncertainties faced by patients and their families, advance care planning, law and ethics, as well as management of common symptoms at the end of life such as pain, delirium, incontinence and swallowing difficulties.

Late recognition of frailty can impede the choice of a place of care and patient-centred decisions. Both lead to inappropriate life-saving interventions and to under-treatment of palliative symptoms and concerns.

A key aim of the new BGS guidance is to prompt and support timely discussions about preferences for care with the older person themselves and their family. It covers the importance of advance care planning and provides advice on how nurses can go about this process.

The guidance also covers the unique considerations applicable in specific settings, such as urgent care, community settings and prisons. It explores issues such as cultural and spiritual needs, and the importance of social and psychological support.

The BGS says the rise of single-organ specialism and technological healthcare has led to improvements in survival, but a narrow approach could lead to clues being missed and time and resources being wasted in pursuit of the wrong goals.

There is also a section linking to COVID-19 guidance. National Institute for Health and Care Excellence guidance states that all adults admitted to hospital for COVID-19 should have a frailty assessment, and this should inform discussions on admittance to critical care.

Expert comment

 

Caroline Nicholson is a professor of palliative care and ageing at the University of Surrey, honorary nurse consultant at St Christopher’s Hospice in London and British Geriatrics Society co-lead for end of life

‘COVID-19 has brought into sharp focus the centrality of providing high-quality care for older people with frailty, who are often vulnerable to poor quality of life in their final years.

‘This new British Geriatrics Society guidance, written from across the multidisciplinary team, is an important clinical resource for nurses providing person-centred care to older people and their families at end of life. It supports the delivery of the best care possible to older people with frailty across all care settings.

‘Crucially, the guidance encourages us to look beyond the patient in our place of work to see the person with a variety of needs and concerns. We, as nurses, wherever we work, are likely to be called on to provide hands-on end of life care to older people with frailty.

‘This guidance helps us to advocate, to coordinate care and to attune ourselves to the older person with frailty and what matters to them as their life comes to an end.’

 

Key points for nurses

  • Although frailty is a leading cause of death in older people, it is often not recognised or considered at end of life.
  • Severe frailty is an end of life state and should prompt a healthcare professional to identify and sensitively discuss end of life needs and preferences.
  • The Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners can be a useful tool to identify needs and to direct a focused care plan.
  • Clinical uncertainty accepts and manages the inherent uncertainties of living and dying well with frailty. The focus moves from identifying dying to parallel planning, in which there are several possible outcomes across specialties, some becoming more obvious over time and some less likely.
  • Professionals may find it hard to discuss clinical uncertainty with older people and families. Evidence suggests that patients and family often want uncertainty to be made explicit, understanding that while death is a possible or probable outcome, it is not certain.
  • One perceived barrier to advance care planning is prognostic uncertainty, which is often seen in frailty. But advance care planning is not just about the end of life: to be most effective and helpful to the person concerned and their clinicians, the process needs to begin as early as possible and to develop as it is reviewed, refined and focused by the shape and characteristics of a person’s frailty or how their deterioration unfolds.

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