The ostrich approach – Prognostic avoidance, strategies and barriers to assessing older hospital patients’ risk of dying

•Hospital aged care assessment teams relied on intuition and pattern matching when identifying older patients at risk of dying.•Personal, interpersonal and systemic barriers such as lack of knowledge and confidence led to prognostic avoidance and a bystander effect among clinicians, resulting in delayed recognition of dying.•Coronavirus-related restrictions intensified these challenges.•Prognostic avoidance must be addressed through tailored training for hospital aged care assessment teams supporting place of care decision-making for older patients.•Future research, policy and practice must consider how pandemic-related mandates like facemasks, telehealth, and visitor restrictions impact clinicians’ ability to detect early signs of dying . Predicting older patients’ life expectancy is an important yet challenging task. Hospital aged care assessment teams advise treating teams on older patients’ type and place of care, directly affecting quality of care. Yet, little is known about their experiences with prognostication. Twenty semi-structured interviews were conducted with seven geriatricians/ registrars, ten nurses and three allied health staff from aged care assessment teams across two hospitals in Melbourne, Australia. Data were analysed thematically. To generate prognoses, clinicians used analytical thinking, intuition, assessments from others, and pattern matching. Prognostic tools were an underutilised resource. Barriers to recognition of dying included: diffusion of responsibility regarding whose role it is to identify patients at end-of-life; lack of feedback about whether a prognosis was correct; system pressures to pursue active treatment and vacate beds; avoidance of end-of-life discussions; lack of confidence, knowledge and training in prognostication and pandemic-related challenges.