Why are nursing home residents sent in to hospital to die?

Those working in acute medicine frequently treat older care home residents who are dying from chronic incurable conditions. These patients are often transferred as an emergency to the acute hospital setting, to receive sometimes formulaic and futile intervention at the end of their life. Commonly such intervention has no effect on eventual outcome but can often be unpleasant and distressing for the patient, their family and the medical team. In most of these situations, open communication, advanced care planning and adequate resources could enable the provision of end-of-life care within the care home, and so prevent unnecessary and undesirable hospitalisation at the end of life. Globally, we are witnessing a changing demographic with population ageing seen throughout the world. In addition to this shifting demographic, we observe that our ageing populations are more often dying from chronic cardiovascular and respiratory pathology, combined with the presence of dementia and frailty.1 These frail older people with multi-system pathology and cognitive impairment exhibit an illness trajectory described as “prolonged dwindling”.2 Their decline towards death can be protracted, variable and difficult to predict. A steadily increasing proportion of these frail older people are living in residential and nursing homes. Care home residents often consider these institutions as “home” and have expressed a wish for their terminal care to occur there.3 Despite the unpredictability of the terminal trajectory in frail older patients, in certain groups the average life expectancy at the time of admission to a nursing home can be as short as 7 months only.4 Professionals involved in caring for this population should be looking to actively manage this end-of-life phase.