Let me tell me you about Jim, one of the first patients I encountered in my role of Frailty Nurse. Of course, Jim is not his real name, but I think it suits his character.
Jim clearly lived a rich and fulfilling life. As a teenager in the Second World War he landed on the Normandy beaches and on leaving the army a straightforward career as a mechanic in the South of England followed. Marrying and raising a family didn’t stop him living his life by the seat of his pants with numerous ‘round the world’ motorcycle trips and up to his 90th birthday he regularly rode motorbikes at the Isle of Man TT races.
However, we all slow down eventually. His wife died a few years ago leaving Jim to adapt to life on his own. A proud independent man, he declined offers of help from his daughter, teaching himself to cook and the intricacies of the washing machine. Shortly after his wife died Jim was diagnosed with prostate cancer. Physically, things became more difficult; getting old can be a bugger sometimes as Jim found out, eventually moving up to the region to live with his daughter who he described as “his shining light”.
I know all this because I sat with Jim and listened to his story one morning in the Combined Assessment Unit. He had been admitted following a fall overnight and his GP thought this, coupled with his cancer, made him sufficiently frail to warrant admission. I couldn’t see anything abnormal in his blood results, my physical assessment gave me no concerns, he had good ‘get up and go’ and yet glancing through his admission paperwork as we chatted I noted his receiving doctor had written
‘Unfortunately there appears nothing we can do other than admit the patient due to his frailty and deterioration’
Frailty can best be described as a decreased resilience, a clinically recognizable state resulting in an aging-associated decline in reserve and function to an extent that the ability to cope with everyday or acute stressors is compromised. But here’s the thing, frailty doesn’t have to be a reason for admission to hospital – in fact, a lot of the time it’s the worst thing to do. People can adjust and they can live with frailty if they are managed holistically and supported back home as soon as it’s clinically safe. Evidence shows that admission to hospital results in increased risk of morbidity and muscle waste as they lose the ability to care for themselves. The same research tells us that people can live longer better lives in a homely environment. Changing the way we think about frailty is crucial for the delivery of high quality, sustainable and, most importantly, patient centred healthcare.
Let’s go back to Jim. We keep chatting, he confides he’s feeling scared; the husband, father and ex-soldier who travelled around the world is worried. It’s all a bit noisy here and the look on his face says I want to go home. We both know if he is admitted to a ward it may be sometime before he gets home and possibly not at all. However, I think about how he describes his daughter as ‘his shining light’ and I turn to the most important diagnostic tool I have, my telephone. A comprehensive history is the most important aspect of frailty nursing; the comprehensive geriatric assessment is essential for identifying effective patient centred care, central to this history taking are families and carers. In this instance Jim’s daughter.
Over the phone his daughter helps me piece the story together. He tripped overnight going to the toilet – that prostate cancer you see, a proud, self resilient man he’s reluctant to ask for help or even use a walking stick. His daughter clearly loves him and she describes how much she wants her dad to spend his remaining time at home with her. We both agree that in these circumstances home is best but, with an air of desperation, she asks how? Luckily, she lives locally and assures me she will be there shortly. As she makes her way to the Combined Assessment Unit I start to devise Jims discharge plan.
The Combined Assessment Unit in Dumfries Infirmary is the front door of the hospital for the majority of our patients. It can be a frenzied, noisy and (at times) a chaotic department where literally anything can happen and usually does at 3am. For twenty-four hours, seven days a week a seemingly never ending conveyer belt of the sick, scared and vulnerable pass through its doors. However, as the front door of the hospital it’s the ideal place for a frailty nurse to be based, pulling frail patients out of the admission process with the support of a unit that fully employs a true egalitarian approach to multi disciplinary team work.
Don’t believe me?
Firstly, I speak to the Occupational therapist and explain the situation; she listens, takes notes and goes to speak to Jim. She’s shortly joined by his daughter and they agree how they can best support Jim at home. A few referral calls and she’s arranged a domiciliary visit in addition to producing a few simple pieces of equipment such as a raised toilet seat to take home. Immediately after, the physiotherapist assesses his mobility, testing him out on stairs and producing a walking frame to help him at home. She’s also contacted her colleagues in the community who agree to visit Jim. Recognising that frailty is likely to affect his ability to metabolise drugs, the pharmacist makes time for us and provides much needed advice on appropriate medication and removing unnecessary medications that may contribute to another fall. She cheerfully chats to Jim and reassures him as she does so. I then mentally prepare a speech to give to the Consultant to argue for Jims discharge; a key part of my role is to advocate for the patient piecing together the team’s actions into a safe discharge. Midway through stating my case a light nod of her head tells me to stop talking as she already agrees with the suggestion. She advises a long-term catheter would minimise the risk of falls at night, I’m slightly apprehensive catheterizing a patient with prostate cancer but the Consultant reassures me. Much to my delight (and presumably Jims) I’m successful first time. A quick phone call to the district nurses who are happy to support Jim at home with the catheter seals the deal.
There is one final step in the plan. The Consultant has a gentle conversation with Jim and his daughter about his future and with the upmost sensitivity agree quality of life rather than longevity is important and a ‘Do Not Resuscitate’ form is signed. An anticipatory care plan is agreed and leaning over an overworked Junior Doctor I ensure its explicitly stated in Jims discharge letter to his GP.
As a result of the contributions and support from a number of patient centred professionals Jim, who I first met at about 9am that morning, was discharged home after his lunch the same day.
In writing this up I wondered how Jim got on at home being looked after by his ‘shining light’. Reviewing his notes he had a fall about 3 months ago, dislodging his catheter. Normally an incident like this would result in a full admission to a hospital ward. However on this occasion, the A&E medic had written:
“Seen previously by frailty team, support plan and clear ACP in place, replace catheter, for home, do not admit”
Hopefully, right now, Jim is at home enjoying a mug of tea whilst browsing through a motorcycle magazine and giving his daughter some light-hearted cheek.
Frailty works. The number of frail patients being discharged directly from CAU rather than be admitted has dramatically increased since the role started, the number of same day discharges has increased substantively as well. This means more beds and less expenditure but behind these numbers are the people like Jim, frail patients who can live happily outwith an acute setting with our support.
Drew Crooks is a Clinical Nurse Specialist in Frailty at NHS Dumfries and Galloway
Professional Portfolio has been available online for nurses and midwives to record CDP evidence for a number of years. It has now been developed for use by the allied health professions (AHPs) – dietetics, occupational therapy, orthoptics, paramedics, physiotherapy, podiatry, prosthetics, radiography, speech and language therapy. 
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