End of Life Care in Frailty: Rehabilitation

Key principles³

Best practice initiatives

Person-centred goal setting

• Work in partnership with people to actively identify their personal priorities and goals. Place these at the centre of your interdisciplinary support for older people living with frailty so all involved are aware of and working together to achieve these.

• In every holistic assessment ask people:

- ‘What matters to you?’
- ‘What would you like to be able to do in the next few (months, weeks, days)?’

• Openly acknowledge and plan for uncertainty. Utilise parallel planning² to support people to ‘hope for the best and plan for the worst.’
   
• Utilise outcome measures to assess a person’s goals such as Goal Attainment Scale (GAS)⁵ or G-AP-PC.⁶
   
• Regularly review a person’s goals and adapt these if necessary if/when their condition or priorities change.

Focus on function

• For older people living with frailty, function is an important indicator of both performance and wellbeing.

• Ensure all members of the interdisciplinary team have a focus on a person’s ability to function including their mobility, activities of daily living and ability to participate in meaningful activities such as accessing their community. This includes considering how any symptoms or medications may be impacting on function.

• Proactively recognising and responding to early changes in function can help reduce falls risks and reduce further functional deterioration.

• Utilise a functional screen to establish a person’s baseline level of function.
   
• Review function at each contact to proactively screen for and recognise a change in function.
   
• Take appropriate actions to optimise people’s functional potential including early referral for physiotherapy and occupational therapy rehabilitation input.

Supported self-management

• Ensure a consistent interdisciplinary approach which views older people living with frailty, and their family or carers, as equal partners and encourages them to play an active role in managing their health and well-being themselves.
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• Early supported self-management can help people to be more resilient and help to prevent crises.

• Practice a ‘strengths-based approach’⁷ to identify each individual’s strengths and resources - including personal, community and social networks - by asking people:

- What’s going well for you right now
- What would you say are your strengths?
- What strategies do you use to cope?
 

• ​​​​​​​Positively reinforce and build upon these.
   
• ​​​​​​​Support people to use non-pharmacological (non-drug) approaches to self-manage symptoms such as breathlessness or fatigue.³
   
• Empower people through knowledge by providing information about their condition, services that are available to support them and how to access these

• ​​​​​​​Proactively offer opportunities for Advance Care Planning.

Enablement

• Empower people to have maximum choice and control over their own lives – through all members of the interdisciplinary team actively creating opportunities for people to choose what they want to do, to undertake what they can themselves and to provide just the right amount of support to meet their individual needs and preferences.

• Adopt a ‘positive risk taking’ approach - which starts from a place or maximising opportunities for people and then balancing the positive benefits gained against the negative effects of attempting to avoid risk altogether.⁸
   
• Always ask people if they need or would like any assistance before assisting them.
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• Where care or support is needed, always ask people how they would like this support and ensure it is delivered in a way that optimally enables people to do what they can for themselves.