Box 1.

Themes emerging from responses to vignettes.

Vignette 1 theme: recognising end of life in care homes

‘Treatment should be palliative. Her daughter will need education and reassurance’ (EM7)

‘This patient needs an anticipatory care plan drawn up’ (GenMed5)

Vignette 2 theme: limiting time in hospital for essential investigations only

‘Not necessarily requiring hospital admission but warrants A&E r/v with x-rays to exclude #NOF’ (A&E4)

‘If possible the ideal would be assessment with x-ray in A&E (phoning ahead to alert the A&E team) and prompt return to care home if no bony injury’ (Ger7)

Vignette 3 theme: difficulties of providing parenteral hydration in care homes

‘May benefit from IV fluids… Can this be done at home?’ (EM8)

‘Short-term use of subcutaneous fluids’ (CHLN6)

Vignette 4 theme: difficulties of providing parenteral treatment in care home

‘The only treatment hospital can add is IV antibiotics’ (Ger1)

‘Would be good if IV antibiotics could be given in the care home setting if required’ (CHLN8)

Vignette 5 theme: difficulties around providing medical procedures in care homes

‘Needs catheter change for urinary retention. Would be nice if this were achievable in the nursing home with outreach services, but my experience is these patients often end up in A&E’ (EM2)

‘This gentleman requires a change of catheter with gentamicin cover’ (GenMed4)

Vignette 6 theme: accessing specialist review in care homes

‘Could patient be discussed with epilepsy team rather than directly admitted?’ (Ger4)

‘follow up with neurology outreach services?’ (CHLN8)

Vignette 7 theme: managing complexity in care homes

‘She needs bloods including INR [international normalised ratio] & urea & haemoglobin. She needs a medication review’ (EM7)

‘Could be managed in care home …. but would take a lot of organising’ (Ger7)

Themes common to various scenarios

Using advance-care planning (ACP): ‘although prognosis is guarded, frailty does not equal do not treat actively – there really needs to be discussion re: ACP’ (GenMed5), ‘ACP would be appropriate with GP and multidisciplinary team’ (CHLN3)

Communication between the patient, their family, care home staff and the healthcare team: ‘The patient's care would be discussed using a multidisciplinary approach’ (CHLN7)