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The NHS next steps review (The Darzi review) also focussed on end of life care which was one of the eight workstreams. Each Strategic health authority in England reviewed its local arrangement for end of life care.

What is the relevance of this emphasis to geriatricians?
As mentioned in the article above, very few people say they would like to die in hospital and yet a significant number do. The group least likely to die in hospices or at home are older people dying of conditions other than cancer; even older people with cancer are less likely than younger patients to end their days in a hospice.

Geriatricians working in hospital settings need to be aware of the End of Life Care Strategy and its parallel policies in Scotland, Wales and Northern Ireland. Most people die of long term conditions (only 5% of people die unexpectedly) so many deaths could be anticipated, and if services are redesigned to be proactive rather than reactive better end of life care could be offered to many.

Geriatricians deal with death frequently and in most departments end of life care pathways, such as the” Liverpool Care Pathway”, are in use. This has been demonstrated to improve the process of end of life care. Nevertheless it is acknowledged that recognition that a patient is reaching the end of their life can be difficult and diagnosis of dying is not always easy, especially by less experienced staff. Thus some patients are subjected to inappropriate invasive investigations or treatments at a time when the emphasis could have been more appropriately on comfort and dignity.

Most geriatricians will have had the distressing experience of caring for a severely ill, very dependent patient who has been inappropriately admitted from a care home to end their days on the acute admissions unit rather than in their own bed in their care home. The End of Life care strategy provides an additional stimulus to the work which has begun in some areas to enhance anticipatory care planning for care home residents, as well as others, so that patients and their relatives can consider end of life care before an emergency situation arises. They can therefore identify where they would like to be cared for at the end of their life and GPs, community nurses, and care home staff can plan in a timely way to avoid inappropriate emergency admissions. In some cases support from community geriatricians will be needed to assist in this work and stimulate its development. The strategy flags up the need for improved support from specialist palliative care where specialist palliative care needs are identified. Often (perhaps more commonly) frail older people will benefit from the support of a geriatrician working with primary care if the patient’s needs are complex (for example where there are issues around medication use, swallowing and feeding issues and indeed, the recognition of the dying phase).

Some geriatricians have expressed concerns that patients will need substantial support to make informed decisions for themselves. Others have rightly expressed concerns that patients who have potentially reversible conditions may mistakenly be diagnosed as coming to the end of their life if they are denied comprehensive assessment by a specialist geriatric team.

Geriatricians will welcome the improvement in quality of care that the End of Life care strategy demands for all people who are dying. Within the hospital environment we will need to continue to make careful assessments of the potential for improvement in our patients and to recognise when the focus needs to move from curative measures to comfort. We need to listen carefully to other members of the multidisciplinary teams and to what patients and their families are telling us about their wishes. The responsibility for clear communication will be even more important, both with patients and their carers, and also with colleagues, in primary, intermediate and social care. Within a community setting we need to ensure that PCTs and practice based commissioners are aware that this change in location of work will enhance the need for community geriatricians to ensure that by avoiding hospital admission, patients are not being denied access to specialist assessment or care when this has the potential to benefit that patient.

A change in the responsiveness of many community services will be needed if the promise of the end of life care strategy is to be delivered. Such improved services would not only benefit those patients at the very end of their life but also help many frail older people to fulfil the aspiration of the “Gold Standards for Care Homes” initiative- to help older people to “live well until they die”

E Burns
Consultant Geriatrician

BGS Newsletter, March 2009
Issue 19 ISSN 1748-6343 20