For nearly one year I have been writing this Frailty blog sharing what I know about frailty, how it impacts the lives of chronically ill people, across all care settings, and much more. If you read any health care literature I expect you have read something else about frailty as it is more often now being studied in the context of managing risk in many specialties and in many settings. Because of this exciting step forward (i.e.recognizing frailty as an indicator of risk and as a condition to be addressed) I want to express my thoughts on developing “Frailty-Informed Care Plans”.
The mandated Comprehensive Care Plan in PALTC does not address the fact that the standard care planning goals: “The patient will” do such and such if we just do the right things does not address the fact that frailty will impact the patient’s ability to achieve those goals – perhaps even more than will the care you are providing to achieve that goal.
For example: The healing of a pressure ulcer, a gain in weight, the increase in walking distance, and many more “goals” may not be achievable if the Frailty Risk Score is moderate or high. The patient cannot “will themselves” to this level of improvement – and that may not be their goal. There are goals that can be informed by the degree of frailty present and that might be achievable, improve outcomes, quality, and satisfaction. Goals of reducing unnecessary medications, improving nutrition in keeping with patient choices, tailoring activity and/or therapy minutes to level of fatigue (a prominent feature of frailty), addressing loneliness and isolation, completing Advance Care Directives, and offering the opportunity for Limitation of Transfer/Treatment orders.
The mandated Comprehensive Care Plan in PALTC does not address the fact that the standard care planning goals: “The patient will” do such and such if we just do the right things does not address the fact that frailty will impact the patient’s ability to achieve those goals – perhaps even more than will the care you are providing to achieve that goal.
For example: The healing of a pressure ulcer, a gain in weight, the increase in walking distance, and many more “goals” may not be achievable if the Frailty Risk Score is moderate or high. The patient cannot “will themselves” to this level of improvement – and that may not be their goal. There are goals that can be informed by the degree of frailty present and that might be achievable, improve outcomes, quality, and satisfaction. Goals of reducing unnecessary medications, improving nutrition in keeping with patient choices, tailoring activity and/or therapy minutes to level of fatigue (a prominent feature of frailty), addressing loneliness and isolation, completing Advance Care Directives, and offering the opportunity for Limitation of Transfer/Treatment orders.
Frailty-informed care planning will be more realistic and satisfying at the same time for the real needs and wishes and potential of the patient can be addressed rather than formulaic goals more attuned to less frail – more fit – residents.