From Recognition to Conversation: Improving Advance Care Planning for older People Living with frailty in Acute Care Settings

From Recognition to Conversation: Improving Advance Care Planning for Older People Living with Frailty in Acute Care Settings

Background

Older people living with frailty have unpredictable illness trajectories, making recognition of the final year of life challenging. Advance care planning (ACP) may be delayed despite recognition of frailty and deterioration during acute admissions. We evaluated the timing of prognosis and end-of-life (EOL) discussions and clinicians’ confidence in initiating them.

Methods

Records of 100 patients who died across three older people’s wards between December 2024 and July 2025 were retrospectively reviewed for recognition of poor prognosis and timing of documented prognosis/EOL discussions. Clinicians completed questionnaires assessing confidence and barriers to ACP. Findings informed targeted teaching, followed by a repeat questionnaire with partial overlap between respondents.

Results

Median age was 86 years (range 67–102). Only 23% were recognised as likely to die during admission, while 60% were not initially expected to die despite documentation of frailty, severe illness or guarded prognosis. Seventeen patients had no documented prognosis/EOL discussion; of 83 documented discussions, 50 occurred within the final week.

Questionnaire responses numbered 22 initially and 27 on repeat assessment. Among foundation doctors, median confidence in recognising patients approaching EOL was 6.5/10 and 7/10 respectively; confidence discussing prognosis was 6/10 and 7/10, while confidence in EOL discussions remained 6/10. Clinical exposure (81.5%), observing senior clinicians (77.8%) and conducting ACP/EOL discussions (77.8%) were most frequently associated with increased confidence.

Conclusion

Recognition of imminent dying was generally good; however, recognition of frailty and an associated poor prognosis did not consistently translate into timely ACP, with many discussions occurring late in the patient’s journey. The findings highlight the challenges trainees face in moving from recognising deterioration to initiating conversations about prognosis and EOL care. While structured education has a role, trainees identified clinical exposure, senior role-modelling and opportunities to participate in ACP discussions as important contributors to confidence. Combining education with supported experiential learning may better equip trainees to initiate timely, person-centred conversations.