The phone rings at two in the morning. "Your mum's running a temperature and she's a bit confused. Do you want us to call an ambulance?"
You have eight seconds, almost no information, and the certainty that whatever you say will be wrong. Say yes and it goes badly, and you sent her to a corridor. Say no and it goes badly, and you denied her treatment.
This page has one purpose: to make sure that call does not find you unprepared. The right decision is not made at 2 a.m. It is prepared beforehand — and in England there is a specific form for exactly this.
1. What an admission actually does to a very old person
This is not an ideological question. Hospitals save lives, and for some things there is no alternative. But the costs deserve saying out loud, because nobody says them:
- Delirium. An older person with dementia taken to A&E at night — lights, noise, strangers, nil by mouth, none of her landmarks — very often becomes acutely confused. That is not a detail: delirium worsens outcomes and does not always fully resolve.
- Deconditioning. A few days in a hospital bed can undo the walking that took a year to maintain.
- The trolley wait. The hours in A&E are the worst part, and the part nobody factors in.
- Hospital-acquired infection and the risks that come with procedures.
None of that is an argument against admission when admission is needed. It is an argument for deciding deliberately rather than reflexively.
2. When hospital is the answer, no argument
Knowing these removes a great deal of anxiety
- suspected fracture, particularly a hip: it needs fixing, even at a great age, because the alternative is pain and immobility;
- stroke signs — face droop, arm weakness, slurred speech: there is a treatment window and minutes matter;
- significant breathlessness, chest pain;
- acute abdomen, persistent vomiting;
- head injury, especially on an anticoagulant;
- bleeding that will not stop;
- anything the home is not equipped to treat.
3. When it can often be avoided — if the home is set up for it
Many admissions from care homes are for things that a well-supported home manages better on site than a hospital does:
- urinary or chest infection responding to treatment;
- dehydration, including subcutaneous fluids;
- fever in someone in the advanced stage of an illness, where admission changes the outcome very little and the last weeks a great deal;
- a fall with no sign of fracture, with observation in place;
- a mild flare of something already known and managed.
The deciding factor is rarely severity. It is what the home can actually do — and that is something to establish in advance, not at 2 a.m.
4. Three questions to ask on the phone
When they call, do not decide immediately. Ask these
- "What have you done already, and what can you do there?" Oxygen, fluids, bloods, antibiotics, a GP or advanced practitioner review, out-of-hours support.
- "What would hospital change, compared with what you can do?" This is the decisive one. If the answer is "they'd run the same tests", the answer is usually no.
- "Has a clinician assessed her, or is this a nurse's judgement over the phone?" Not a criticism — information about how solid the assessment is.
And a fourth that always helps: "Call me back in an hour with how she is." A great many situations resolve within the hour.
5. The form that prevents all of this
This is the part most families have never heard of.
ReSPECT — Recommended Summary Plan for Emergency Care and Treatment — is a form completed with a clinician that records what matters to the person and what should and should not happen in an emergency. It is not legally binding, but it travels with her, and it is what the paramedic reads at 3 a.m. instead of guessing. Most care homes and ambulance services use it.
Alongside it
- An Advance Decision to Refuse Treatment (ADRT) is legally binding under the Mental Capacity Act, if valid and applicable — and it must be in writing, signed and witnessed if it covers life-sustaining treatment.
- A DNACPR decision is about cardiopulmonary resuscitation only. It does not mean "no treatment", and families routinely misunderstand it. It is a clinical decision, but it must be discussed with the person or those close to her.
- A Lasting Power of Attorney for Health and Welfare — and only that one, not the property and finance LPA — lets an attorney make treatment decisions, and only covers life-sustaining treatment if the form says so explicitly.
The sentence to say to the home: "I'd like a ReSPECT conversation for my mother with the GP. Can we arrange it?"
That single meeting converts the 2 a.m. call from an impossible decision into applying something already agreed, in daylight, with a clinician present.
6. If she can no longer say
With no ADRT and no health and welfare LPA, decisions are made in her best interests under the Mental Capacity Act — taking into account her past wishes, feelings, beliefs and values, and consulting those close to her.
Note the wording: family members are consulted, they do not decide, unless they hold a health and welfare LPA or a court deputyship. Which is precisely why telling the clinician what she used to say — "she never wanted to be kept going on machines", "she'd want everything tried" — is not sentiment. It is the material the decision is built from.
7. If she does go in
A few practical things that make a large difference
- Go to A&E if you possibly can. A confused older person alone on a trolley for six hours is the worst version of this.
- Take the medication list, the home's details and the GP's.
- Tell the receiving staff immediately that she has dementia. It changes how she is managed. Ask about the hospital's "This is me" document or dementia passport.
- Ask that restraint is avoided and that someone can stay with her.
- Push for discharge as soon as it is safe — every extra day costs mobility — and confirm the home is holding her bed.
For the paperwork and for the search
If the 2 a.m. call happens because the home cannot treat anything on site, then the problem is not that one night. It is the home.
Curalune Care Help (£69) puts together, usually within 24 working hours, a shortlist of 3 to 5 homes matched to her area and needs — with contacts and the questions to ask about nursing cover and GP support.
*General information, not medical advice. In an emergency call 999. Every clinical decision belongs to the clinician who has assessed the person.*
