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Key Actions for Change

  1. Individual care plan – this needs to be part of the patient care plan once severe frailty/last year of life diagnosed. It should be developed with the patient and those who care for them.
  2. Anticipatory prescribing and medication optimisation/deprescribing - common symptoms can be relieved simply if timely consideration to an individual’s care management is made in advance. Drugs that may cause harm/don’t add value may be reduced/stopped.
  3. Education for the HF service multi-disciplinary team – local education sessions mandated into general practice of EoL services to ensure current practice and local guidelines are known and adhered to within operational service guidelines.


Areas of Interest

Frailty & Palliative Care

  • Early identification of patients who have frailty or being in the last year of life - When patients are identified with having frailty or being at the end of their life, their management should be changed to a more holistic approach [as per comprehensive geriatric assessment (CGA) for frailty] and advance care planning for EOL. System tools available to support identification of frailty score, and those who have of life indicators, including using GSF and SPICT. Patients are often not diagnosed with their frailty which can put them at risk of falls and drug side effects. Early identification of frailty, and those approaching the latter stages of life is essential as it changes management, can reduce the chance of hospital admissions, empowers patients and acts as a gateway to virtual wards.

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