From Crisis DNACPR to Proactive Planning: Advance Care Planning for Care Home Residents With Frailty
Abstract
Background
Care home residents with advanced frailty often experience repeated acute transfers near the limits of clinical benefit, yet anticipatory planning may be absent until crisis admission. This audit assessed availability of comprehensive Advance Care Plans (ACPs) before transfer and whether acute admission was associated with reactive resuscitation-focused documentation.
Methods
A retrospective review was undertaken of 146 acute medical admissions from care homes to Prince Philip Hospital between 1 September 2024 and 30 April 2025. Electronic records were analysed for Clinical Frailty Scale (CFS), ACP documentation on admission and discharge, do-not-attempt cardiopulmonary resuscitation (DNACPR) status, inpatient mortality and 3-month unscheduled readmission. Isolated DNACPR decisions were analysed separately from comprehensive ACPs.
Results
Frailty was advanced: 91/146 residents (62.33%) had CFS ≥7. Only 8/146 (5.48%) had a comprehensive ACP on admission, rising to 18/146 (12.33%) at discharge. Conversely, DNACPR documentation rose from 51/146 (34.93%) to 125/146 (85.62%). Inpatient mortality was 25/146 (17.12%). Of those who died, 17/25 (68.00%) had CFS ≥7 and all 25 lacked an ACP on admission. Unscheduled 3-month readmission occurred in 26/146 residents (17.81%); 20/26 (76.92%) lacked an ACP, with secondary care stays ranging from 7 to 14 days.
Implementation and Conclusions
The audit identified a marked gap between proactive anticipatory planning and late inpatient DNACPR documentation. Findings were presented at the Whole Hospital Audit Meeting and a Health Board clinical advisory group, where they were adopted to inform existing regional Treatment Escalation Plan (TEP) workstreams. Multi-agency workstreams across acute medicine, older people’s medicine, primary care and care homes are implementing standardised TEP templates, community education and discharge-process prompts. Cycle 2 will evaluate admission ACP visibility, discharge TEP completion and readmission-related bed days.
Comments
This is a highly relevant…
This is a highly relevant and impactful audit addressing an important gap in anticipatory care planning for frail care home residents. The findings clearly highlight the discrepancy between comprehensive advance care planning and reactive DNACPR documentation during acute admissions. The strength of this project lies in its translation into practice, with findings informing regional Treatment Escalation Plan initiatives and promoting multidisciplinary collaboration. The planned second audit cycle will be valuable in assessing the sustainability and impact of these interventions on patient care and avoidable hospital admissions.
Reply to Moh.yousif@gmail.com
Thank you, Moh. There’s still a lot of work being done to bridge this gap, and I’m encouraged that several key stakeholders are giving it the attention it deserves. Hopefully, these collective efforts will translate into meaningful, sustainable change, making advance care planning a routine and integral part of patient assessment and care, rather than something considered only during acute admissions.