Home-based Nurse Intervention in the Care of High Risk of Death Patients After Discharge From Geriatric Department

To be considered for this study, you would need to be 75 years old or older and covered by a social security scheme. You must have recently been in a hospital ward specialising in care for older people, and be going home or to a care home for elderly people who need support. You should also have a serious ongoing illness or a condition that cannot be cured, and doctors need to believe you are at high risk of dying in the 12 months after leaving the hospital.

There are also some reasons why you couldn't join. For example, if you or your family say you don't want to take part, or if you're being moved to another type of hospital ward like rehabilitation or palliative care. You also can't join if you've already made an advance care plan, chosen someone to speak for you in health matters, or already talked about your end-of-life wishes with your doctor. Finally, if you have severe memory problems or another condition that makes it hard for you to understand and make decisions about your future care, you wouldn't be able to participate.

The study doesn't involve new medicines or treatments. Instead, if you're invited and agree to join, you'll be assigned to either receive the usual care you would get, or to receive support from a nurse at home to help you create an Advance Care Plan. The study aims to see how practical and effective this support is. You would likely have follow-up contact for about a month to check on your progress with the care plan. The total duration of your active involvement in the study would be fairly short, with researchers checking if care plans are made within the first month. There will be no specific number of visits described here, as it depends on individual needs and the study design.