The drive to discharge older people with frailty at the end of life from community hospital. A constructivist grounded theory study

There has been an increasing acknowledgement in recent years of the importance of recognising frailty as a condition that leaves older people vulnerable to dramatic, sudden changes in health triggered by seemingly small events such as a minor infection or a change in medication or environment. Older people with frailty are those who are at highest risk of adverse outcomes such as falls, disability, admission to hospital, and the need for long-term care. The approach to managing frailty is often with an emphasis on staying well, even though, due to an increase in conditions such as dementia, heart disease, stroke and arthritis, Seymour (2017) suggests, 'end-of-life care' is 'care of older people'. Meanwhile, discharge from hospital continues to be contentious, with overstretched acute hospitals juxtaposed with community services that struggle to keep up with the demand of those being discharged. Studies that look at the combination of frailty, end of life and hospital discharge are limited. Furthermore, previous studies looking at these areas focus on perceptions of health professionals or patients and informal carers, but not on stakeholders as a whole.

This qualitative study explored the experiences of stakeholders involved in the discharge from hospital of an older person living with frailty who is nearing the end of life. This included the patient, their informal carer(s), community hospital staff, community health professionals and care home managers. A constructivist grounded theory methodology was used, and semi-structured interviews were conducted with 55 participants. The interview data were analysed and interpreted using the constant comparative method and situational analysis.

The study findings provided valuable insight into the experience of older people living with frailty approaching the end of life, their informal carers and health professionals involved in the discharge from community hospital. The study added to the knowledge of the discharge process for all stakeholders. The core category of 'the drive to discharge conveyor belt' was produced from the data analysis alongside four dynamic, interrelated conceptual categories and the subcategories within these. These conceptual categories were: 'resource limitations', 'mismatch in expectations', 'choice and control' and 'carer burden'. The study captured how the discharge conveyor belt is caused by and causes resource limitation, mismatch in expectations between health professionals, patients and carers and how concepts of choice and control influence decision making. These concepts combine to increase the carer burden. The carer was found to be 'intrinsic' to the discharge and facilitating the older person living in their place of choice. Intersectionality was used to interrogate how the drive to discharge intersects with older people and their informal carers to create inequitable outcomes, and to generate recommendations.