From Crisis DNACPR to Proactive Planning: Advance Care Planning for Care Home Residents With Frailty

Introduction

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.