The number of people in the UK aged over 65 is growing and is forecast to reach 16.1 million by 2035. The burden of disease associated with aging will increase as will the demands on health services including end-of-life and palliative care. The National Confidential Enquiry into Patient Outcome and Death in 2008 found that rather than advanced care planning and palliation taking place, some patients were subjected to excessively active interventions in their last months of life.
The pilot study aimed to ascertain whether using primary and secondary care data to identify patients at risk of hospital admission and agreeing and implementing an Anticipatory Care Plan in this population could help to reduce hospital admission rates. Anticipatory care planning allows patients to express their wishes for care prior to a sudden deterioration in their health.