The Impact of Advance Care Planning for Care Home Residents with Dementia on Hospital Admission and Death in Preferred Place of Care

Consultant Older People’s Services, United Lincolnshire Hospitals Trust, UK

*Corresponding Author:

Garden G
Consultant Older People’s Services
United Lincolnshire Hospitals Trust, United Kingdom
E-mail: gill.garden@stbarnabashospice.co.uk

Received date: May 05, 2016; Accepted date: May 07, 2016; Published date: May 12, 2016

Citation: Garden G (2016) The Impact of Advance Care Planning for Care Home Residents with Dementia on Hospital Admission and Death in Preferred Place of Care. J Palliat Care Med 6:261. doi:10.4172/2165-7386.1000261

Copyright: © 2016 Garden G. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Discussion

Psychiatry and Geriatrics have long been regarded as the Cinderellas of Medicine, but surely care home medicine is the real Cinderella. Despite being some of the most vulnerable members of society, care home residents often have poor access to health care and very short life expectancy. Although functional decline and health crises are inevitable, they are often treated as unexpected, and managed reactively by an outdated model of healthcare with acute hospitals at its heart.

So what are the alternatives?

There is good evidence from Canada and Australia [1,2] to suggest that many of the health needs of care home residents can be managed in their own environment without resort to hospital admission, with no adverse effect upon mortality and with greater satisfaction for both patients and carers.

As a liaison psychiatrist I had first-hand experience of the plight of people with dementia admitted to hospital, sometimes in their dying hours or days. Well-meaning and often futile intervention was common, but profoundly distressing for both patients and their loved ones, who rarely had the benefit of previous discussion about health, prognosis and preferences. Our local surge in admissions of people from care homes in late 2009 was frustrating for doctors and nurses on the wards, since many of these patients seemed to be admitted solely to die, and the staff were aware of the inadequacies of the system but felt unable to influence it. Knowledge of the literature and the fortuitous meeting with a member of the Bromhead Medical Charity at a dementia workshop led to a successful application for a grant to set up a service for people with dementia living in care homes in Boston, Lincolnshire.

The service comprised two Registered General Nurses experienced in the care of older people supported by myself. The cornerstones of the service were training of care home staff in recognition, management and prevention of delirium [3], a frequent cause of admission, together with assessment of residents with reference to Gold Standards Framework Prognostic Indicator Guidance [4] and advance care planning either with the resident, or if they lacked mental capacity on a best interests’ basis with their family. Additional training was developed on end of life issues associated with dementia, especially eating and drinking problems and dysphagia, which were also common reasons for hospital admission.

The service was evaluated using admission data from the preceding 12 months and collected monthly after commencement of the service. Carer satisfaction was measured using an anonymous questionnaire and staff confidence and knowledge assessed before and after training sessions. Admissions to the acute hospital fell by 37% in the first year of service and by 55% in the second and third years. Staff confidence in recognition management and prevention of delirium and end of life issues increased significantly together with more modest improvements in knowledge. Most importantly, all but one of our residents with a care plan died in their preferred place of care and carers expressed great satisfaction with the service. The service cost £100k per annum, but the net saving in admission costs over a two year period were calculated to be between £240k and £470K. Whilst the fall in admissions may have reflected a number of factors of which our service was one, the results lead to the local Clinical Commissioning Group funding the service recurrently, which has expanded the number of care homes it serves and has broadened its remit to cover people with frailty too. A report on this service has been published recently in Clinical Medicine [5].

References

1. Molloy DW, Guyatt GH, Russo, R, Goeree R, O'Brien BJ, et al. (2000) Systematic Implementation of an Advance Directive Program in Nursing Homes. JAMA 2000; 283: 1437-1444.
2. CaplanGA, Meller A, Squires B, Chan S, Willett W (2006) Advance care planning and hospital in the nursing home. Age Ageing 35: 581-585.
3. Siddiqi N, Young J, House A, Featherstone I, Hopton A, et al. (2011) Stop Delirium! A complex intervention to prevent delirium in care homes: a mixed-methods feasibility study. Age Ageing40: 90-98.
4. Thomas K, Free Al (2011) Prognostic Indicator Guidance. Gold Standards Framework.
5. Garden G, Green S, Pieniak S, Gladman J (2016) The Bromhead Care Home Service: the impact of a service for care home residents with dementia on hospital admission and dying in preferred place of care. Clin Med 16: 114-118.