This study consists to evaluate the feasibility of a case-management intervention of Advance Care Plan (ACP) placement for elderly patients at high risk of death at twelve months discharged alive from acute geriatric medicine.
Feasibility will include the following indicators: rate of patients included and randomized, rate of patients remaining in the study, ACP rates achieved at one month.
Patients aged 75 or over.
Affiliated to a social security scheme.
Hospitalized in an acute care geriatric department
Discharged from hospital to home or residential facilities for dependent elderly people
Refusal to participate in the study expressed by the patient or his/her legal representative, if applicable.
Patients transferred to another Medicine-Surgery-Obstetrics department (only "medicine or surgery" in the elderly).
Patients transferred to follow-up care and rehabilitation, palliative care, or returning home in palliative care.
Patients who have already drawn up advance directives, chosen a trusted support person or discussed their end-of-life wishes with their doctor.
Parallel
Advance care plan
Other interventionScheduling of 2 home visits by an expert nurse in the month following the return home and proposal to carry out an advance care plan.
Ergonomic analysis
Other interventionErgonomic analysis throughout the intervention
Evaluation of intervention acceptability
Other interventionEvaluation of intervention acceptability after each home visit with patients and caregivers using a questionnaire
Rate of included patients
Rate of patients remaining in the study
Advance care planning rate achieved
Rate of compliance to advance directives
Rate of compliance with the patient's advance directives one year after discharge from hospital; compliance to the the following situations will be identified: * The patient is still alive: wishes to be re-hospitalized / does not wish to be re-hospitalized / has not made a decision. * The patient is deceased: place of death specified: hospital, home or other / no decision taken.
Hospital Anxiety and Depression Scale (HADS) of caregivers and carers
Anxiety-depressive symptomatology of caregivers will be assessed using the Hospital Anxiety and Depression Scale (HADS) in the event of patient death, if this occurs within one year of discharge from hospital. The HAD scale is a screening instrument for anxiety and depressive disorders. It comprises 14 items rated from 0 to 3. Seven questions relate to anxiety (total A) and seven to depression (total D), giving two scores (maximum score for each = 21). To screen for anxiety and depressive symptoms, the following interpretation can be proposed for each of the scores (A and D) each of the scores (A and D): * 7 or less: no symptoms * 8 to 10: doubtful symptomatology - 11 or more: definite symptomatology.
Questionnaire to evaluate the acceptability of the intervention
The acceptability of the intervention will be assessed by a questionnaire after each home visit at 7 days and one month, with patients and caregivers in the intervention group.
EQ-5D-3L scale score
Changes in the quality of life of patients and caregivers one month after hospital discharge will be measured by changes in the EQ-5D-3L scale score. EQ-5D is a standardised measure of health-related quality of life.n EQ-5D-3L, the five dimensions each have three response levels of severity. Respondents are asked to choose the statement in each dimension that best describes their health status on the day they are surveyed. Their responses are coded as a number (1, 2, or 3) that corresponds to the respective level of severity: 1 indicates no problems, 2 some problems, and 3 extreme problems. In this way, a person's health state profile can be defined by a 5-digit number, ranging from 11111 (having no problems in any of the dimensions) to 33333 (having extreme problems in all the dimensions).
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