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

Lille Catholic University

Status: Not yet enrolling

Conditions: Advance Care Planning; Health Services for the Aged

Treatments: Other: Evaluation of intervention acceptability; Other: Advance care plan; Other: Ergonomic analysis

Study type: Interventional

Funder types: Other

Identifiers

NCT06481917

RC-P00119

Details and patient eligibility

About

This study consists to evaluate the feasibility of a case-management intervention of Advance Care Plan (ACP) placement for elderly patients at high risk of death at twelve months discharged alive from acute geriatric medicine.

Feasibility will include the following indicators: rate of patients included and randomized, rate of patients remaining in the study, ACP rates achieved at one month.

Enrollment: 104 estimated patients

Sex: All

Ages: 75+ years old

Volunteers: No Healthy Volunteers

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.

Trial design

Primary purpose: Prevention

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

---

104 participants in 2 patient groups

Advance care plan

Experimental group

Description:

Scheduling of 2 home visits by an expert nurse in the month following the return home and proposal to carry out an advance care plan.

Treatment:

Other: Ergonomic analysis

Other: Advance care plan

Other: Evaluation of intervention acceptability

Usual care

No Intervention group

Description:

Usual care with the possibility of proposing ACP according to the department's habits