An evaluation of healthcare professionals’ decision-making in the care of frail older people at end of life

There is a global demographic shift toward an ageing population, and in the UK the proportion those aged 65 and over continues to rise (ONS 2017). As people age, they are progressively more likely to live with complex co-morbidities, disability and frailty (Kings Fund 2014). Frailty has been acknowledged as a key priority NHS England with the need to provide timely, proactive support for older people as they continue to age (NHS England 2014;2017). Therefore this evaluation aims to evaluate the influence of policy and practice on the decision-making of professionals to inform service delivery. This evaluation utilised a case narrative approach to explore professional decision-making that underpinned the care of three deceased frail older people. Data was collected in two phases, a comparative review of the clinical documentation followed by narrative interviews of professionals. Ten professionals from nursing, occupational therapy and physiotherapy participated across 3 cases. Data analysis was iterative, informed by the narrative reality conceptual framework (Connelly and Clandinin 2000). Two grand narratives emerged, these were the clinical story of care of a frail older person reaching end-of-life and professional’s stories of decision-making. Grand narrative one set out the clinical story of care, providing a contextual account of frailty and end-of-life from a professional perspective. Grand narrative two explored the professional’s stories in supporting a frail older person reaching end-of-life. The practice implications centred on the process of care for frail older people and how medicalisation of ageing and death resulted in protocol-driven, asynchronous technical care. The aim of care being to diagnose and treat illness and functional decline within a deficit-based decision-making approach, whereby independence and risk management were the foci of decision-making. The paradigm of active ageing has been incorporated into professional decision-making leading to an absence of end-of-life care needs being considered within practice. The theoretical implications indicate that a transitional understanding of frailty may offer a critical lens through which to recognises the individual needs of older people. The evaluation recommendations focus on developing the competencies of professional decision-making by utilising recognised tools to support the identification and management of frailty, guiding professionals to consider the holistic needs of the older person within the context of everyday life including end-of-life-care. To achieve this, there needs to be investment in developing the leadership of all professional groups especially AHP in contributing to Frailty pathways, thus ensuring care is targeted at the three core transitional phases of rehabilitation, habilitation and palliation. In doing so the divergence between policy and practice can be challenged, thus incorporating end-of-life care explicitly into NHS organisational goals for older people.