Introduction
Older people approaching the end of their life can experience an acute exacerbation or a complication of their illness. [1] When these sudden changes are life-threatening, the situation is often called an emergency as it requires an urgent response. Health and aged care professionals play a central role in providing acute medical care in these situations. [1,2]
A high number of emergency transfers from residential aged care (RAC) to hospital/ED occur in the last months of life and this trend is likely to increase in Australia and other countries. [1-4] These transfers are commonly due to trauma (usually from a fall), an acute infection or an altered mental state. [1,2] Here we consider emergency planning and management in the context of older people living in the community either in RAC or in their own homes.
Quality Statement
Of the literature retrieved pertinent to emergency planning and management, eight reviews in an aged care and palliative context were found. [3-10] Six reviews were in an aged care context but did not focus on end-of-life; [1,2,11-14] and five were in a palliative care context but not specific to older adults or an aged care. [15-19] Two meta-analyses were conducted. [2,7] Other sources of information were included to provide context to this topic. [20-26]
Overall, the quality of the reviews included in this synthesis was good, with most reviews considered acceptable or of high quality. Only three of the twelve reviews were considered of low quality due to their reporting on methodology and quality assessment. [6,12,19]
Evidence Synthesis
Emergencies may be completely unexpected. [21] Some may be anticipated from the thorough assessment of a person’s disease and symptoms. Current advance care plan documentation can reduce the risk of poor communication and unnecessary or unwanted invasive treatments in the event of a change or decline in health. [1,3,12]
Emergency health management
Unplanned admissions to the ED or hospital can be distressing for an older person and their family and a stay in hospital is associated with complications including pressure ulcers, functional decline, medication errors and delirium. [1-3] Many older adults with serious and life-limiting illness present to Emergency Departments (EDs) with an acute (perhaps reversible) deterioration in health. [15,16]
Lemoyne et al. [1] found that the factors that influence decisions (and their appropriateness) to transfer a resident from RAC to ED were:
- access to a complete and current advance directive or similar documentation
- whether discussions for end-of-life care had been held and any plans made and documented
- perceived quality of acute medical care in residential aged care and in ED/hospital
- expectations of relatives and their communication with residential aged care staff
- GP availability, particularly after hours
- nursing staff capacity to manage chronic conditions, acute conditions, end-of-life planning, and fall prevention
- level of aged care staff training.
Communication with family influences transfer decisions and they often act as a “gap filler” between the residential aged care facility (RACF) and the hospital when information about the resident and their medication is lost during the transfer. [2]
Many of the above findings are supported by Bone et al. [3] who also found that when older people have their palliative care needs met, they are less likely to be transferred to an ED in the last year of life. Earlier initiation of palliative care also lowered the likelihood of presentation to an ED. [3]
Emergency medicine providers often have limited training or resources for palliative care which can result in individual and care preferences not being considered in this setting. [15,16] Approximately half of all frail older adults discharged home within 72 hours from acute care are re-admitted and one third die within a year of the admission; the majority of these events occurring in the first 90 days following discharge. [10]
A similar review examining the use of emergency services by older adults with dementia, found that ambulance crews frequently find it difficult to obtain medical information and assess symptoms which often results in emergency department admissions, especially out-of-hours. [8] Emergency visits for older adults with dementia are more likely to become admissions and are associated with higher mortality than for older adults without dementia.
The review by Buswell et al. [8] found that training of emergency staff in how to manage older adults with cognitive impairment was lacking. Absent also were alternatives to hospital admission in these scenarios. A meta-analysis by Carpenter et al. [7] found that in older adult emergency department (ED) patients, the Abbreviated Mental Test (AMT-4) most accurately ruled in dementia, and the Brief Alzheimer’s Screen most accurately ruled out dementia. They are preferable to the MMSE in the ED environment because as their names indicate, they are brief and relatively easy to conduct. [7] Both tests help in determining where a formal cognitive assessment or Comprehensive Geriatric Assessment could be useful. [7]
Although early initiation of palliative care in the ED may contribute to less hospitalisation, greater quality of life and help older people remain at home at end of life [4], it requires adequate community support to be effective. Currently there is insufficient evidence on which to base strategies to improve palliative care in the ED or reduce admission to ED. [4,15,16]
George et al. [17] conducted a review of the literature to examine screening criteria and tools to identify people in the ED with palliative care needs. The review found several 1-step or 2-step pathways or tools which demonstrated positive outcomes but the body of evidence is small with wide variability in criteria used for screening. A review by Green et al. [19] found, in one study, that half of the patients eligible for palliative care in hospital had been admitted via the ED. This suggests a need for better screening and referral or management in the community. A significant number of these presentations to ED were due to ‘not coping at home’ and feeling safer in a hospital environment. [19] In these cases, many of the participants felt that an admission could have been avoided if they had had adequate community services and support or their doctor had visited them at home. [19]
Extended Care Paramedics (ECPs) or Community Care Paramedics are an emerging role in out-of-hospital palliative care. [20,22,24] With their additional training and equipment for servicing community palliative care needs, ECPs or Community Care Paramedics can help a person receive care in the place or community where they feel they belong and without unnecessary admission to hospital.
Acute care - early discharge planning
The systematic review by Conroy et al. [10] examined the evidence for services developed to manage frail older adults in their admission to and discharge from acute care. The two models discussed incorporated different geriatric assessments. Comprehensive Geriatric Assessments (CGAs) have, in general, a large body of favourable evidence. However, in this review, the implementation of geriatric assessment pre-discharge did not impact on mortality, long-term institutionalisation, readmission or quality of life outcomes. [10]
Community strategies for prevention of acute care admissions
Staffing levels and seniority of staff in RAC is seen as an important aspect of reducing hospitalisations, with the presence of nurse practitioners and registered nurses (RNs) associated with a lower number of acute care admissions. [14] Where there is a higher ratio of care assistants to nursing staff, unplanned emergency admissions from RAC are more frequent. It was noted that in <44% cases had the older adult been reviewed by the general practitioner before being transferred to acute care. [14]
Slack et al. [6] reviewed the implementation of out-of-hours telephone support to people in their own homes. This service was associated with improvements in symptom management and anxiety as well as facilitation of coping with the dying process. To support such services, the review notes that staff need continuing education to maintain expertise grounded in evidence-based practice, as well as access to electronic health records for communication with other health professionals. [6] It is anticipated with services such as this, ED visits can be reduced, and older adults could be better supported in their wish to remain in the place they call home at the end of life. [6]
Bull et al. [11] reviewed the benefits of educating family carers to recognise the symptoms of delirium as an intervention for unnecessary emergency admissions. Delirium in older adults is considered a medical emergency as it contributes to a cascade of functional decline and increased mortality.
Delirium
Delirium is observed in up to 85% older adults receiving palliative care in all care settings and is characterised by the sudden onset of confusion, inattention and illogical or incoherent speech with additional symptoms of agitation, hallucination or excessive drowsiness and lethargy. [9,11,18] In the review by Clegg et al. [13] interventions for the prevention of delirium in residential aged care is explored, particularly as the incidence of cognitive impairment in older adult residents is high.
The cause of delirium is multifactorial, and unlike dementia, it is potentially reversible if recognised early and the underlying cause treated. Family carers or aged care staff in frequent contact with the older adult are ideally placed to notice a change in behaviour and therefore strategies to educate carers to prevent or manage delirium may reduce incidence or duration of an episode as well as reduce carer distress. [11] The findings of two reviews are not conclusive. [11,13] While educating family carers seems to reduce the incidence of delirium, carer distress and the number of emergency admissions, the evidence is not robust. [11] While a hydration intervention did not demonstrate improvement in hospital admissions, falls or mortality in older adults in RAC, electronic flagging of medications associated with delirium showed some reduction in the incidence of delirium. [13]
Non-pharmacological delirium interventions appear feasible for older people requiring palliative care yet there is no definitive evidence that they are effective or acceptable for this group. [18]
Eighty per cent of people with Parkinson's disease (PD) develop dementia, and with or without dementia, people with Parkinson's disease have an increased risk of delirium. [9] Distinguishing between dementia and delirium in people with Parkinson's disease requires careful assessment as certain symptoms are common to both. [9] When delirium is diagnosed, a first approach is to identify and treat the underlying cause (e.g. infection, dehydration etc.). Altering or suspending PD medication needs to be done with care as this may worsen motor symptoms or increase the risk of delirium. [9]
Advance care planning
Having a written document with care preferences or a nominated substitute decision-maker, means a person is more likely to receive care in line with their wishes should they not be able to express themselves. [5] This is particularly important in end-of-life care where the focus may be quality of life rather than life-prolonging interventions. The timing of discussions for advance care planning and who should initiate and review an ACP, is still very much debated in the literature and, in practice, is highlighted as a barrier to effective and timely emergency care planning. [5,8,12]
Planning ahead may help the quality of care in preparation for the following possible situations [25] :
- a transfer by ambulance, or if triple zero is called,
- a transfer from residential aged care facility to hospital,
- upon presentation to an emergency department,
- review in a crisis by a medical practitioner who is not familiar with the person or their management plan.
Older adults are frequently managed for multiple comorbidities and cognitive and functional impairment. One review [12] notes that each year up to 75% of residents in aged care facilities are transferred to a hospital emergency department for acute changes in health. This is much more than their community counterparts and likely reflects the generally poorer health status of RAC residents. Oulton et al. [5] found that despite a mandate for all people admitted to an emergency department to be asked about completing an ‘advance directive’, completion rates remain low even for chronically ill older adults. This is attributed to poor health literacy, procrastination or lack of discussion for the need for one with their primary physician. The reviews by Dwyer et al. [12,14] recognise that despite the intensive use of acute services, older adults transferring to acute care from residential aged care (RAC) often have adverse clinical outcomes or die during admission. If implemented appropriately for residents in aged care facilities, a current ACP may reduce emergency hospitalisations. [14]
Summary
In summary, older adults requiring palliative care are often at risk of receiving treatments not aligned with palliative care or their wishes. A high number of this population present to emergency departments and are at risk of acute care admission. Advance care planning and an accessible current ACP could improve care pathways for these individuals. [14] A referral system within the ED to palliative care specialist teams has the potential to improve outcomes for this population. To prevent readmission to acute care a number of community strategies that empower individuals and their carers in symptom management seem to be effective. [14]
Evidence Gaps
- Increased understanding of why older adults present to emergency departments is needed
- Specific screening tools for any palliative care need in the emergency department setting are still emerging [26]
- The impact of palliative care management by primary care practitioners on the avoidance of palliative care emergencies and transfers to ED/hospital is unknown
- Research is needed on identifying actions or changes in emergency medicine that can drive earlier referral of people to palliative care to prevent transfers to ED
- Assessing if access to after-hours medical or nurse practitioner support reduces ED admissions is an area in need of research
Page updated 28 June 2021