Background Our current healthcare systems are designed around periods of acute illness and are ill equipped to meet the needs of multimorbid and frail adults with worsening mobility, cognition and function. According to The Irish Longitudinal Study on Aging (TILDA), Ireland has a high proportion of hospital deaths, indicating inadequate community and home care supports. Recognizing patients who are likely to benefit from supportive and palliative approaches with a goal to die at home can be done using a combination of tools and based on advanced care planning discussions. Methods In 2021, our Department for Older Persons Services allocated a team consisting of a Registrar and Advanced Nurse Practitioner in Frailty to form an outreach service. Inpatients who appear nearing end of life who have expressed wishes to avoid further hospitalization and to die at home are identified during their admission. Home visits allow for a holistic assessment and family members are given the opportunity to ask questions. We provide education on end of life, trying to anticipate needs and often see patients and families through periods of deterioration until they stabilize again in a ‘new normal’ or begin the process of active dying. We communicate with Public Health Nurses, General Practitioners and the Community Palliative Care Team. Results Families and carers supporting loved ones who wish to avoid further hospitalization and die at home benefit from combined medical and nursing support & specialist expertise the team brings. Conclusion Addressing end of life for multimorbid patients living with severe frailty is a global challenge. Hospital admission is an ideal time to begin conversations regarding goals of care and initiate advanced care planning. The outreach team work together with hospital and community colleagues to the common goal of following patients’ wishes at end of life.

中文翻译：

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管理社区中体弱老年人的临终需求：以医院为基础的社区外展团队的作用


背景 我们当前的医疗保健系统是围绕急性疾病时期设计的，不足以满足行动能力、认知和功能恶化的多病和体弱成年人的需求。根据爱尔兰老龄化纵向研究（TILDA），爱尔兰的医院死亡比例很高，表明社区和家庭护理支持不足。可以使用多种工具并基于高级护理计划讨论来识别可能受益于支持性和姑息性方法并以在家中死亡为目标的患者。方法 2021 年，我们的老年人服务部分配了一支由登记员和衰弱高级执业护士组成的团队，组成外展服务。那些看似生命即将结束、表示希望避免进一步住院并在家中死亡的住院患者在入院时会被识别出来。家访可以进行全面评估，并且家庭成员有机会提出问题。我们提供临终教育，试图预测需求，并经常帮助患者和家人度过病情恶化的时期，直到他们在“新常态”中再次稳定下来或开始主动死亡的过程。我们与公共卫生护士、全科医生和社区姑息治疗团队进行沟通。结果 支持希望避免进一步住院和在家中去世的亲人的家庭和护理人员受益于团队带来的综合医疗和护理支持以及专业知识。结论 解决严重虚弱的多病患者的生命终结问题是一项全球性挑战。入院是开始讨论护理目标和启动高级护理计划的理想时机。 外展团队与医院和社区同事合作，以实现遵循患者临终意愿的共同目标。