Home-based Nurse Intervention in the Care of High Risk of Death Patients After Discharge From Geriatric Department

Launched by LILLE CATHOLIC UNIVERSITY · Jun 25, 2024

Keywords

ClinConnect Summary

This clinical trial is looking at a new approach to help older patients who are at high risk of death after leaving the hospital. Specifically, it aims to see how effective a home-based nurse intervention can be in helping these patients create an Advance Care Plan (ACP). An ACP is a way for patients to express their healthcare preferences for the future, especially about end-of-life care. The study will measure how many patients participate, how many stay in the study, and how many successfully create an ACP within one month after being discharged.

To be eligible for this trial, participants need to be at least 75 years old, have been hospitalized in a geriatric department, and be discharged to their home or a residential facility. They must also be considered at high risk of death within the next year based on specific health criteria. It's important to note that patients who have already made their end-of-life wishes known or those with severe cognitive disorders will not be included in the study. This trial is not yet recruiting participants, but it aims to provide valuable insights into improving care for elderly patients facing serious health challenges.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • Patients aged 75 or over.
• • Affiliated to a social security scheme.
• • Hospitalized in an acute care geriatric department
• • Discharged from hospital to home or residential facilities for dependent elderly people
• • Targeted pathology or at least one incurable disease.
• • At high risk of death in the twelve months following discharge according to the DAMAGE prognostic score (high-risk score group). A high risk of death is defined by a DAMAGE score \> 50%.
• • Rockwood Clinical frailty scale score greater than or equal to 7 at one month.
• Exclusion Criteria:
• • Refusal to participate in the study expressed by the patient or his/her legal representative, if applicable.
• • Patients transferred to another Medicine-Surgery-Obstetrics department (only "medicine or surgery" in the elderly).
• • Patients transferred to follow-up care and rehabilitation, palliative care, or returning home in palliative care.
• • Patients who have already drawn up advance directives, chosen a trusted support person or discussed their end-of-life wishes with their doctor.
• • Patients with proven severe neuro-cognitive disorders (in the medical record with a Mini-Mental State Examination (MMSE) score below 10 or in the absence of knowledge of the degree of severity and/or a recent previous MMSE score taken in a stable period, the referring practitioner, a geriatrician with expertise in this field, will assess whether the patient is unfit to state his or her advance directives at the time of inclusion.