The editorial1 and accompanying article2 in the October edition of the BJGP highlighted the problems of advance care planning in older people. We detail below the tragic consequences of failure to have these conversations.
A review of case notes of patients registered with a local CCG, who were over 75 years of age and died after spending no more than 1 night in hospital between 1 January 2013 and 31 March 2013, showed that there were 31 such deaths. Of these, eight came from nursing or residential homes and five of these patients were recorded as being unresponsive or had a GCS of 3 when first seen by the ambulance crew. At least six of the patients would have met the Gold Standards Framework prognostic indicators criteria for being on the palliative care register, and in two the family requested admission or resuscitation in case of collapse.
At least four of these cases were pre-alerted to hospital and taken directly into the resuscitation area for multiple investigations and treatments: frail older patients, clearly nearing the end of life, precipitated into hospital where staff feel an obligation to try to preserve life. Most of these patients do not have the mental capacity to understand what is going on around them, and probably find the interventions extremely distressing. The whole process serves only to cause unnecessary suffering.
In some cases the family were not prepared for the patient’s demise, and in most the care institutions were not confident in the management of patients nearing the end of life. The ambulance services are put under considerable pressure and without clarity from the carers will understandably default to an active resuscitation mode.
It is a challenge to primary care to champion the rights of older people to die peacefully.
- © British Journal of General Practice 2013