Why patients in specialist palliative care in-patient settings are at high risk of falls and falls-related harm: A realist synthesis

Abstract

Background: Falls are the third highest reported safety incident in Specialist Palliative Care in-patient settings and yet specific risk factors connected with falling and associated outcomes in this setting are poorly understood. Aim: To understand the key individualised risk factors leading to falls in specialist in-patient palliative care settings and understand the implications and outcomes for the patients who fall. Design: A realist synthesis of the literature, reported following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards. Data sources: An iterative literature search was conducted across three recognised health collections as well as grey literature from policy, practice and other relevant areas. Results: Falls taking place within in-patient specialist palliative care settings can cause significant harm to patients. The risk factors for these patients are multifaceted and often interlinked with underpinning complex realist mechanisms including a history of falls, the age of the person, impact of complex medications, improving functional status and the presence of delirium. Conclusion: In-patients in specialist palliative care settings are at risk of falling and this is multifactorial with complex reasoning mechanisms underpinning the identified risks. There is a significant impact of a fall in this cohort of patients with many sustaining serious harm, delayed discharge and both physical and psychological impacts.

Prevalence of falls in the last weeks of life and relationship between falls, independence, and quality of dying: A secondary analysis of a large prospective cohort study

“…Delirium increases the risk of falls because it can manifest as rapid fluctuations in alertness, attention, and behavior. Moreover, the neuroleptics/antipsychotics often used to treat it may increase the risk of falls [4,27]. In addition, in this study, men were more likely to fall.…”

“…Furthermore, falling was not associated with the GDS scores. In previous studies, patients who fell were more likely to have a "greater fear of losing independence," "avoid asking for help," and "feel uneasy about asking for help" [4,6].…”

“…Patients who fell were more likely to have more delirium during hospitalization. Previous studies [4,22] have shown that delirium is more likely to result in falls. Delirium increases the risk of falls because it can manifest as rapid fluctuations in alertness, attention, and behavior.…”

“…Furthermore, falling was not associated with the GDS scores. In previous studies, patients who fell were more likely to have a “greater fear of losing independence,” “avoid asking for help,” and “feel uneasy about asking for help” [4,6]. Nevertheless, in this study involving healthcare providers in a hospice setting, the GDS was not influenced by the presence or absence of falls, indicating that although fall prevention is considered a priority, healthcare providers should support patients’ desires to move on their own to maintain independence, and it may be possible to maintain independence and quality of dying even for patients who have fallen.…”

“…These patients are usually in the final stages of their illness and may have reduced mobility and strength, increasing their dependence on care and support. Falls in this vulnerable stage can lead to fractures, bleeding, and other serious complications [3][4][5], increasing the burden faced by terminally ill patients and causing pain and suffering beyond the physical realm.…”