Are care homes the hospices of the future?
Dr Sarah Russell is a Carer and Nurse and tweets @learnhospice, George Coxon is a Care Home Owner and tweets @CoxonGeorge and Dr Ros Taylor MBE is Palliative Care Physician and Care Home trustee and tweets @hospicedoctor
Palliative care is relevant across the illness trajectory for people living and dying with chronic progressive conditions, aiming to improve quality of life and enable a peaceful death. With an ageing population, an increased proportion of older people will need to access care and support in a long term care facility. Indeed, over the next 25 years, care homes will become the most common place of death. Hospice care aims to affirm life and death, however they are now considering new ways to reach more people beyond the walls of their buildings.
If living and dying well is a priority for our ageing population, then palliative care and geriatric practice have much to offer each other. Indeed, discussions at the recent British Geriatrics Society Spring meeting reflect this discourse. In the past, Balfour Mount also commented: “both make the whole person and his or her family the focus of care, while seeking to enhance quality of life and maintain the dignity and autonomy of the individual”. A recent review concluded that Integrated Geriatric Care or Palliative Care were effective in improving end of life for older people. Both included person-centred care, education, and a multi-professional workforce. As a family carer in a nursing home, Sarah Russell reflects: “the palliative and geriatric care approaches are incredibly supportive when living with co-morbidities, ageing, dementia, frailty and end of life”. A recent study reported that care homes were one of the most common preferred place of death for people with dementia, especially those with reduced function. This is particularly important given the increase in the projected number of people dying from dementia by 2040. Comprehensive Geriatric Assessment, with its concentration on frail older people with complex problems, seems relevant because care homes offer continuity of care over time, knowledge of the person and time spent preparing the person for a good death.
There are challenges at the palliative and geriatric care interface. Hockley (2017) cautions to be alert to the subtle differences so that we do not impose a model of palliative care developed for cancer onto the care of frail older people. Moore et al (2019) points out the difficulty of delivering palliative care for short-stay residents while simultaneously providing a residential home for long-stay residents. There is also the dilemma of [palliative] terminology used differently in different professional backgrounds. Whilst finding a consensus is challenging, consistency about the words and definitions used do matter as they have an impact for individuals, service providers, commissioners and evaluators in terms of care design, delivery, evaluation and experience.
It is time to actively support care homes as the first-choice places of living, caring and dying. Ros Taylor points out “as a palliative doctor and a trustee of a large care home in south London, I am seeing great preparations for better endings, brave conversations and plans, alongside a real focus on living life to the full’. But there is pressure for healthcare support in UK care homes, with a potential for a blame culture which can test one system’s trust in another. George Coxon (ambassador for John's Campaign in care homes and a founding member of the provider-led coalition Devon Care Kite Mark), reminds us that choice, dignity, and round the clock care are reliant on strong partnerships: “these partnerships must start with those we have with our residents, their families and loved ones and also prioritise our NHS health partners and specialist palliative care services working in a trusting and trusted way”. Indeed, it has been suggested that improved outcomes are achieved in an environment where visiting practitioners and care home staff had a sense of common purpose and confidence in each other’s skills, together with recognition from health and social care organisations that care homes are valued partners.
Chronic phases of illness and increasing multimorbidity present growing challenges requiring a new approach to care homes e.g. a wrap-around infrastructure characterised by a network of health and social care teams offering relational support and expertise. Whilst there is evidence that there can be a lack of palliative care knowledge in care homes, initiatives such as the Proactive Health Care of Older People in Care Homes (PEACH) study illustrate real world research experiences of collaborative improvement. Further examples, including Enhanced Health in Care Homes , ENRICH and Teaching Care Homes, demonstrate their potential as innovation centres showcasing excellence in care and promoting research and quality improvement programmes.
In a time of economic, political, cultural, health and social uncertainty, there is more to unite than divide in hospice, palliative and geriatric care. If healthy ageing in the last years of life is concerned with the duality of living the best life possible, whilst at the same time adapting successfully to gradual deterioration; then now is the time to focus on integrating services in care homes.
Perhaps the question is not ‘are care homes the hospices of the future’, but rather “what are we doing to support and enable care homes as the hospices of the future”?