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Emergency admissions may be an appropriate time to start advance care planning for older people. New research found that people over 70 generally welcomed these discussions in hospital.

Advance care planning allows people to think and talk about the care they would like to receive, including in their final months of life. These discussions are particularly important for older people. They may cover emotional and practical issues around death and dying, and can include treatments that people do not want to have. However, health and social care professionals may feel reluctant to start discussions.

In this study, researchers wanted to find out if admission for emergency care is an acceptable time to start advance care planning discussions. They explored the views of a group of people over 70 who were admitted for an emergency stay in hospital. They also looked at rates of death after an emergency admission in people over 70. 

They found that, like a previous study in Scotland, around 1 in 5 people over 70 die within a year of an emergency admission. Advance care planning was generally welcomed by the people in this study, who valued the expertise of clinicians in planning future care.  

The work shows that emergency admissions could serve as a trigger for starting advance care planning discussions for people over 70. The team hopes that the work will prompt health and social care professionals to initiate discussions with confidence, knowing that they help guide patients. 

Further information on advance care planning is available on the NHS website.

What’s the issue?

People in the last months or years of life have the right to express their wishes about the care they would like to receive.  They need to be able to understand how their disease is progressing, what their treatment options are, and where they could be cared for. Good end of life care is tailored to the person who needs it. That person, and those close to them, should be at the centre of all decisions. 

Advance care planning is a series of discussions involving the person, those close to them and the staff caring for them. An individual plan of care should be agreed, and written down. It can cover any aspect of future health or social care and should be updated as circumstances change.  

The national health agenda has included advance care planning for more than 10 years. It can be started at any point, but is particularly recommended when someone is believed to have one year or less to live. But many professionals are reluctant, or confused about when to initiate advance care planning. 

This study explored whether emergency admissions in patients over 70 years would be an appropriate time for these discussions. It examined how likely people aged 70 and over are to die within a year of an emergency admission. The research team also sought patients’ views of advance care planning.

What’s new?

The study included 14,260 emergency admissions for people aged 70 and over. Their admissions to the Imperial College Healthcare NHS Trust occurred in 2014-2015. The researchers also looked at records of deaths for the following year (2015-2016). 

The study found that, among this group of people over 70 who had been admitted to hospital as an emergency:

    • one in five (22.6%) died in the 12 months following the admission
    • most (59%) deaths occurred within 3 months of the admission
    • increasing age increased the chances of death within 12 months 
    • men over 70 were more likely to die within 12 months than women of the same age.

The team went on to interview 20 people who were admitted to hospital as an emergency. They asked people for their views on advance care plans. Three key findings were reported.

1. Benefits to health and wellbeing: interviewees felt that advance care planning with family and health and social care professionals could improve their physical and emotional wellbeing. They saw practical benefits in discussing the monitoring and care they would receive for a long-term illness, plus the help they could ask for in a crisis.

I think everybody would want to know their prognosis and I think the doctors should tell them… they can get in touch with their family and tell them… so they can all get together… they’ve only got six months to live, they can sort their plans out… so when they pop off, they think, ‘I’ve done everything, I’ve looked after everybody… now I can go with ease’.” Mrs. WP

2. Contemplation of physical decline and death: interviewees said that advance care planning prompted them to think about their physical deterioration. It helped them accept a life-limiting diagnosis. The discussions helped them prepare for the end of life. This included planning their funeral and reflecting on mortality.

I’m sure he wouldn’t want his life prolonged more any longer because there was no hope, and we agreed to let him fade away and I feel I did the right thing…” Mrs. R

3. Collaboration with health and social care professionals: interviewees recognised the expertise of various professionals including GPs, hospital staff and multidisciplinary teams. Some people would prefer to have these conversations with professionals rather than their families.

I’d rather have a doctor explain to me what the situation was, and I’d go along with them, you know what I mean?” Mrs. B

Why is this important?

The work shows that around 1 in 5 (22.6%) people aged over 70 years with an emergency admission to hospital are in their last year of life. This figure is similar to that found in previous studies. The authors suggest that emergency admissions should trigger advance care planning for people over 70 years. 

The researchers hope this work will normalise advance care planning. They would like health and social care professionals to see it as a process rather than a one-off conversation. 

The study found that most people over 70 would be expected to live for more than a year. The team said that for these people, the discussions could be about their future health and wellbeing. They stressed that advance care planning is a spectrum and is not just about end of life care. 

The study emphasises the need to share electronic care plans across different settings such as hospital, primary care, or hospice. This would help ensure that advance care plans are acted upon. People should be able to access their own care plans.

What’s next?

The current work aimed to raise awareness of, normalise, and find an appropriate trigger for advance care planning. The team hopes the study will give health and social care professionals the confidence to raise advance care planning with patients.

People who are expected to live less than a year could have a frailty assessment by a geriatrician. This assessment could guide advance care planning.

This study has some limitations. Older people were open to advance care planning, but not all those approached agreed to be interviewed. It is possible that those who refused the interview were less open to advance care planning. In addition, it focused on the number of emergency admissions; some patients might have been admitted to hospital more than once. And the study was carried out at a single trust hospital. It would be useful to ask people in other areas their views on advance care planning.

You may be interested to read

This NIHR Alert is based on: Bielinska AM, and others. Advance care planning in older hospitalised patients following an emergency admission: a mixed methods study. PLoS ONE 2021;16:3

NHS ‘Coordinate my care’: an NHS service that builds medical care around the wishes of each patient.

Advance care planning information from the charity Marie Curie

Treatment and care towards the end of life: good practice in decision making - guidance for clinicians from the General Medical Council. 

A paper exploring the uptake of advance care planning: Knight T, and others. Advance care planning in patients referred to hospital for acute medical care: Results of a national day of care survey. EClinicalMedicine 2020;19:100235 

A paper looking at the views of advance care planning in caregivers of older hospitalised patients: Bielinska AM, and others. Views of advance care planning in caregivers of older hospitalised patients following an emergency admission: a qualitative study. Journal of Health Psychology 2021; doi: 10.1177/1359105320926547 

 

Funding: This work was supported by the NIHR Imperial Biomedical Research Centre. 

Conflicts of Interest: One author is clinical lead for the NHS service ‘Coordinate my Care’, another is supported by a grant from the same service. 

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Commentaries

Study author

We want to encourage health and social care professionals to consider emergency admission a ‘teachable moment’ and an opportunity to start advance care planning with patients. We wanted to emphasise that advance care planning shouldn’t be a taboo subject. The responses we had from patients suggest that they largely agree.  As health and social care professionals, we need to recognise that patients will often look to us to support these discussions.Advance care planning is a process of repeated discussions, not a one-off. A patient’s wishes can change over time. Advance care planning is a spectrum of discussions and should be individualised to each patient.Anna-Maria Bielinska, Clinical Research Fellow, Imperial College London and Imperial College Healthcare NHS Trust 

Geriatrician 

This paper will raise awareness about advance care planning; the findings are likely to apply across the UK. The work indicates that an acute hospital admission is a potentially valuable time to discuss advance care planning.However, advance care planning is best carried out within an existing and sustained relationship. Hospital admissions are becoming shorter; patients may not be in hospital long enough for such a relationship to be built. Even if planning involves hospital physicians, most plans will be fulfilled in the community or care home. Records therefore need to be shared between settings to enable quicker access to high quality palliative care, for example. There is more to do in the hard-pressed community to ensure that patients' preferences at the ends of their lives are respected.The findings are in line with my clinical experience, but are incomplete. They are limited by the fact that people with significant cognitive impairment were not included. As an acute physician for older people with frailty, I see many patients and their families who are reluctant to discuss advance care planning in hospitals. This is particularly so when decisions have to be made on behalf of someone who lacks capacity (best interest plans).John Gladman, Geriatrician, Nottingham University Hospitals NHS Trust 

Member of the public  

I am 80, fortunate to be articulate, proactive, an easy communicator and able to form relationships of trust with a wide range of people. I have recovered from cancer and am in good overall health, but I am aware that I may at any time suddenly find that my situation has changed and be admitted as an emergency to an A&E department. Before leaving hospital, I would want my family to make joint decisions with me and the hospital clinicians, and to share my advance care plan with my GP.Some of the interviewees demonstrate the widespread confusion among patients and families (as well as professionals) about the various steps involved in preparing for dying. There is a profusion of terms and acronyms. Families are often more reluctant than patients to address openly the reality of impending death. Some professionals are palpably unable to find the language they need to interact with empathy and compassion with patients.This paper made a huge impression on me and will live in my thoughts. I have always managed my own life as well as the lives of others, and see an advance care plan as a way of helping to manage my own death. The openness, honesty and sensitivity of the research mean that it could have a huge impact.Ann Whitfield, Community Leader & Patient Citizen Leader and Public Contributor, Nottinghamshire 

Occupational Therapist 

This paper is relevant for anyone that works with people over 70. Obviously not everyone in this group will be receptive to the idea. But for those who are, addressing the issues with experienced health professionals can have a huge impact on their physical and psychosocial health.It is unclear how generalisable the findings might be across the diverse UK population. But I think all professionals working with people over 70 have a role to play in asking questions about advance care planning. They need to understand and discuss with people what their wishes and concerns are.Joy McLaggan, Senior Occupational Therapist, Hampshire 
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