This page does not aim to be comprehensive. 
It seeks to guide you to think about predictable clinical problems that commonly arise in the following situations.
Common things happen commonly. Frail patients commonly fall over, develop infections and become delirious (confused or muddled simply from being unwell).
People know about this stuff but like to think it will happen to someone else. Grasp the opportunity when it occurs. If a patient has been admitted following a fall, infection or delirium then now is the time to discuss and ask how they would like it managing next time. 
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It's more difficult to deny the risk if it has just happened.

And, the final thing to remember is that we are not thinking about how to manage a problem in hospital (Consultants and Registrars can worry about that), but in the patients home in the wee small hours.
Failure of Care (Carer crisis, equipment, accommodation)

Frailty

• Poor Oral Intake

• Infection

• Delirium

• Failure of Care

• Dying

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• Treatment Escalation Level	Poor oral intake (often with aspiration risk) Management Plan and Wishes :
  ITU	Trial of community management where feasible and safe If poor diet and fluid intake cannot be managed in the community, admit to hospital for further investigation and intravenous fluids +/- supportive nutrition
  Hospital	Trial of community management where feasible and safe. If poor diet and fluid intake cannot be managed in the community, admit to hospital for further investigation and intravenous fluids +/- supportive nutrition
  Home	Declining oral intake is a common symptom of end stage frailty & other illnesses. Artificial nutrition is not indicated, and so hospital admission would not be beneficial. Follow any specific SaLT or dietetics plan (if one is in place). Manage at home with supportive measures by encouraging diet and fluids. Offer food and drink the person enjoys Offer regular mouthcare Trial oral nutritional supplements if appropriate Consider reversible causes (such as infection, constipation, poor dentition, oral thrush) that could be treated with oral medications. Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. If oral intake continues to decline despite above measures, then consider whether this an end of life situation. If so, arrange anticipatory/palliative medications and move to comfort measures.
  Comfort	​Consider whether this is an end of life situation. ​Anticipatory medications in place, use as required. Food/flavour, if requested and able. Administer mouth care including oral cleaning, ice chips, occasionally artificial saliva to alleviate symptoms of dry mouth. Thirst is rarely a feature. Moisten the lips/lip moisturizers Ensure Community Team supporting and Package of Care sufficient to support patient and family needs.
• Treatment Escalation ​Level	INFECTION (Chest/Urine/Unknown Source)​​ Management Plan and Wishes :
  ITU	​​​Consider source of infection & starting appropriate oral antibiotics. If deteriorating on oral antibiotics or not feasible, then admit to hospital for possible IV antibiotics. ITU admission will be decided in hospital as appropriate.
  Hospital	Consider source of infection & starting appropriate oral antibiotics. If deteriorating on oral antibiotics or not feasible, then admit to hospital for possible IV antibiotics. Does not wish to be admitted to ITU.
  Home	Consider source of infection & starting appropriate oral antibiotics. Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. If deteriorates despite oral antibiotics, consider whether this is an end of life situation. Move to comfort measures
  Comfort	Consider source of infection & starting appropriate oral antibiotics, if feasible and wanted. Anticipatory meds. in place, use as required. Ensure Community Team supporting and Package of Care is sufficient for patient & family needs.
• Treatment Escalation Level	Delirium Management Plan and Wishes :	Notes
  ITU	Investigate possible causes. Manage at home as appropriate. If deteriorating on oral treatment, then admit to hospital for further investigation. ITU admission will be decided in hospital as appropriate.	Consider whether appropriate if past history of dementia, a progressive neurological or palliative condition
  Hospital	Investigate possible causes. Manage at home as appropriate. If deteriorating on oral treatment, then admit to hospital for further investigation. Does not wish to be admitted to ITU.	See above. Patient, or family if LPOA for H&W is in place, may also wish to limit other treatments.
  Home	Investigate possible causes. Manage at home as appropriate. If deteriorates despite oral treatment, consider whether this is an end of life situation.	This option is only likely to be appropriate on a background of a palliative diagnosis or expected recurrent delirium. Seek specialist advice as appropriate.
  Comfort	Anticipatory meds. in place, use as required. Ensure Community Team supporting and Package of Care is sufficient for patient & family needs.

Fall with . . . 

• Suspected Fracture

• Head Injury

• Long Lie

• Laceration

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• Treatment Escalation Level	Fall with suspected fracture ​Management Plan and Wishes :
  Hospital	Offer analgesia for any pain. Assess post fall and convey to hospital if concerns about a fracture. ​
  Home	Offer analgesia for any pain and prescribe a supply.  Assess post fall and only convey to hospital if concerns about a long bone fracture  are very difficult to pain control without fixation). If fracture unlikely, stable or comfortable, wishes to remain at home. Consider reversible causes of a fall (such as infection, constipation, urinary retention) that could be treated with measures at home.  Consider involving local community urgent response service/virtual ward/frailty team for further monitoring and support. If concerns about a significant fracture, consider referral to hospital for XR assessment, but discuss with patient and/or family first. Plan to be discharged back home as soon as possible after assessment, unless operative management is indicated. Not to remain in hospital for investigation or management of unrelated issues unless agreed with the patient and/or family.
  Comfort	Only convey to hospital if concerns about significant painful fracture (e.g. neck of femur) where operative management would be considered and after discussion with patient and/or family. Consider any operative management only as a palliative procedure to relieve pain and with discharge home as soon as practicable. If no concerns about significant fracture, treat any pain with analgesia. Consider whether this is an end of life situation. Anticipatory/palliative medications in place, use PRN. Move to comfort measures.
• Treatment Escalation Level	Management Plan and Wishes :
  ITU	ITU admission will be decided in hospital as appropriate.
  Hospital	Does not wish to be admitted to ITU.
  Home	Is aware of the risk of an intra-cranial haemorrhage and would not want active neurosurgical treatment. Please do not convey to hospital for brain imaging. Manage conservatively. If deteriorates, consider whether this is an end of life situation. Move to comfort measures
  Comfort	Anticipatory meds. in place, use as required. Ensure Community Team supporting and Package of Care is sufficient for patient & family needs.
• Treatment Escalation Level	Management Plan and Wishes :
  Hospital
  Home
  Comfort
• Treatment Escalation Level	Management Plan and Wishes :
  Hospital
  Home
  Comfort