• Stephen Barclay, Katherine Froggatt, Clare Crang, Elspeth Mathie, Melanie Handley, Steve Iliffe, Jill Manthorpe, Heather Gage, and Claire Goodman.
• Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge.
• Br J Gen Pract. 2014 Sep 1;64(626):e576-83.

BackgroundOlder people living in care homes often have limited life expectancy. Practitioners and policymakers are increasingly questioning the appropriateness of many acute hospital admissions and the quality of end-of-life care provided in care homes.AimTo describe care home residents' trajectories to death and care provision in their final weeks of life.Design And SettingProspective study of residents in six residential care homes in three sociodemographically varied English localities: Hertfordshire, Essex, and Cambridgeshire.MethodCase note reviews and interviews with residents, care home staff, and healthcare professionals.ResultsTwenty-three out of 121 recruited residents died during the study period. Four trajectories to death were identified: 'anticipated dying' with an identifiable end-of-life care period and death in the care home (n = 9); 'unexpected dying' with death in the care home that was not anticipated and often sudden (n = 3); 'uncertain dying' with a period of diagnostic uncertainty or difficult symptom management leading to hospital admission and inpatient death (n = 7); and 'unpredictable dying' with an unexpected event leading to hospital admission and inpatient death (n = 4). End-of-life care tools were rarely used. Most residents who had had one or more acute hospital admission were still alive at the end of the study.ConclusionFor some care home residents there was an identifiable period when they were approaching the end-of-life and planned care was put in place. For others, death came unexpectedly or during a period of considerable uncertainty, with care largely unplanned and reactive to events.© British Journal of General Practice 2014.

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