Home-based Nurse Intervention in the Care of High Risk of Death Patients After Discharge From Geriatric Department

Inclusion Criteria: * 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. Exclusion Criteria: * 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 in…