Advance care planning uptake in the severely frail

Older adults with severe frailty (Clinical Frailty Scale [CFS] 7-9) have high short-term mortality and are often approaching the end of life. Despite this, uptake of Advance Care Planning (ACP) remains low. This study aimed to examine the rate and timing of ACP referral and completion among hospitalized patients with severe frailty.

We conducted a retrospective observational study of patients aged ≥ 65 years with documented CFS scores of 7-9 admitted to the geriatric medicine wards of a public tertiary hospital in Singapore between July and September 2024. The primary outcome was the proportion of patients with completed ACPs. Secondary outcomes included ACP referral and completion rates, time from admission to ACP referral and completion, mortality at 30 days and 6 months, stated care preferences, and place of death. Descriptive statistics were used to summarize patient characteristics and outcomes.

Among 86 patients with severe frailty (mean age 84.8 years; 72.1% female), 14 (16.3%) had completed ACPs prior to admission. Of the remaining 72 patients, 17 (23.6%) were referred for ACP within 90 days, of whom 6 (35.3%) completed ACP discussions. In-hospital mortality was 5.8%, and 6-month mortality was 31.4%. Among patients who died within 6 months, 69.5% died in hospital. Patients with completed ACPs more frequently died at home or with home hospice care.

Our study demonstrates that hospitalized patients with severe frailty have high short-term mortality but low rates of ACP referral and completion. Earlier and systematic initiation of ACP at the point of frailty identification may improve alignment of end-of-life care with patient preferences and reduce unwanted hospital deaths.