Marie Paule LEBITASY

CONTACT

William's VAN DEN BERGHE

CONTACT

Lead Sponsor

Lille Catholic University

Age

75 - No limit years

Sex

ALL

Healthy Volunteers

No

•Patients aged 75 or over.
•Affiliated to a social security scheme.
•Hospitalized in an acute care geriatric department
•Discharged from hospital to home or residential facilities for dependent elderly people
•Targeted pathology or at least one incurable disease.
•At high risk of death in the twelve months following discharge according to the DAMAGE prognostic score (high-risk score group). A high risk of death is defined by a DAMAGE score \> 50%.
•Rockwood Clinical frailty scale score greater than or equal to 7 at one month.

•Refusal to participate in the study expressed by the patient or his/her legal representative, if applicable.
•Patients transferred to another Medicine-Surgery-Obstetrics department (only "medicine or surgery" in the elderly).
•Patients transferred to follow-up care and rehabilitation, palliative care, or returning home in palliative care.
•Patients who have already drawn up advance directives, chosen a trusted support person or discussed their end-of-life wishes with their doctor.
•Patients with proven severe neuro-cognitive disorders (in the medical record with a Mini-Mental State Examination (MMSE) score below 10 or in the absence of knowledge of the degree of severity and/or a recent previous MMSE score taken in a stable period, the referring practitioner, a geriatrician with expertise in this field, will assess whether the patient is unfit to state his or her advance directives at the time of inclusion.