62 A survey of advance care planning in patients with severe frailty on the complex medicine unit of a general hospital

Introduction The 2021 Getting It Right First Time (GIRFT) National Specialty Report for Geriatric Medicine emphasised the need to improve end of life care for frail older patients, referencing advance care planning (ACP) as a 'powerful tool'. This survey sought to evaluate ACP practice for inpatients with severe frailty in 2022. Areas assessed included treatment escalation planning (TEP), cardiopulmonary resuscitation and ACP (prior to admission or new discussions). Methods In a retrospective audit on the Complex Medicine Unit-CMU (~2000 patients admitted annually, mean age~82, pre-frail and frail) of the John Radcliffe hospital, cases were selected by convenience sampling of consecutive admissions per quarter of 2022. Inclusion criteria for further analysis; verified clinical frailty score (CFS) ≥7, survival to discharge, without palliative care follow-up. Results Among 32 patients with verified CFS ≥7 (mean age/SD=86.25/7.35, 15 male, mean length of stay/SD=11.8/8.9 days) 56% died within a year of admission. A pre-existing ACP was documented in 4 (12.5%), discussed and initiated during admission in 5 (15.6%). Enquiry about lasting power of attorney was made in 8 (25%) and in place in 5 (15.6%). No patient had documentation of an advance directive. Fourteen had pre-existing do not attempt resuscitation (DNAR) decisions and DNAR was discussed with a further 13 patients (total DNAR decisions=27, 84%). Inpatient TEPs were documented in 5 (15.6%). Conclusion Although advance care planning as part of proactive palliative care is a priority for older patients in the last phase of life, we found that in severely frail inpatients with high risk of death within the year, <20% had evidence of ACP and TEP suggesting that opportunities for ACP were rarely taken. Current GIRFT requirements for routine in-hospital frailty screening will enable targeting of proactive ACP which should be prioritised in this patient population to improve care and prevent avoidable readmission.