The incorporation of palliative care to address the needs of the older adult is a vital part of emergency medicine. Recognizing the trajectory of chronic diseases in older adults and the myriad of medical diseases amenable to palliative care is paramount. Early involvement of palliative care should be considered the cornerstone to overarching management of the older adult presenting to the emergency department.
The geriatric population is more likely to have serious and chronic illnesses that benefit from palliative care involvement.
Recognition of disease processes amenable to palliative care should be standard practice for emergency medicine physicians.
Understanding the unmet needs of the geriatric population amenable to palliative care can change the trajectory of care in a positive manner.
Introduction and epidemiology
Emergency physicians routinely care for patients with serious illness. Geriatric patients are more likely to have life-limiting illnesses and also suffer from a significant burden of chronic disease. Since its recognition as an official subspecialty of emergency medicine (EM), palliative care (PC) has become better appreciated and its importance with respect to caring for chronically ill persons recognized.
As the population in the United States continues to age, with baby boomers now retiring at a rate of 10,000 individuals per day, a corresponding increase in Medicare costs, especially among patients with chronic disease, has increased substantially. This concomitant increase in older adults, patients with chronic disease, and associated costs creates a health care system likely to benefit from the further involvement and consideration of palliative care.
Furthermore, given that emergency departments (EDs) are seen as the safety net in any health care system, many older adults with exacerbation of chronic disease are seen in this setting. Often these patients, who increasingly have challenges accessing primary care, never return to their baseline after these exacerbations. Moreover, these ED visits increase toward the end of life. Approximately 15% of people younger than 84 years old visit the ED in the last 6 months of life, while 75% of people older than 84 year old visit the ED in the last 6 months of life, with half of these patients presenting during their last month of life. , , For these reasons, it is imperative that PC practices and interventions be considered a standard part of any EM physician’s armamentarium.
Despite the rather recent recognition of PC in the ED, its value in addressing the needs of the geriatric population in this setting has been demonstrated in the literature. Early PC intervention has been shown to decrease depression, improve quality of life, and extend life expectancy by almost 3 months. It also has been shown to decrease length of hospital stay. It is recognized not all EDs may have PC consultants available; the involvement of the primary care physician (PCP), outpatient PC referral, virtual PC consultations, and social work consultation may be a more feasible alternative.
Incorporating PC into one’s practice in the busy environment of the ED may be challenging; however, it is important to recognize that EM physicians are often caring for patients at a pivotal point in the trajectory of a chronic disease. These encounters offer EM physicians the opportunity to intervene and introduce the support PC can offer patients and their families in the setting of serious illness. Therefore, the EM clinician has to be facile at rapidly assessing for potential PC needs within the geriatric population.
It is important to distinguish PC from hospice care. PC focuses on specialized medical care for people living with a serious illness with the goal of improving quality of life for both the patient and the family. PC involvement can begin at any phase of a serious illness, including at the time of diagnosis. Hospice, on the other hand, is care in the last phase of a life-ending illness. The role of PC in treating the patient and the family as a unit is especially important in geriatric patients, for whom there is often significant caregiver involvement and fatigue. In addition, older adults are more likely to have polypharmacy and under-recognized symptoms requiring careful symptom management. Early involvement of PC should be considered a cornerstone in the management of the older adults with chronic diseases presenting to the ED. Fig. 1 illustrates the difference in disease trajectory and continuum of support between early and late PC intervention.
Interventions and considerations
Recognizing Opportunities for Palliative Care Involvement
PC is often associated with hospice, when in actuality, hospice is only a small part of the spectrum of PC. The World Health Organization describes PC as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Life-threatening illnesses include not only cancer but also congestive heart failure, end-stage liver disease and renal disease, advanced chronic obstructive pulmonary disease (COPD), and advanced neurocognitive diseases such as Alzheimer disease and Parkinson disease. Recognizing that these chronic conditions, which are often debilitating and negatively impact quality of life, are amenable to PC is paramount. The geriatric population is likely to have at least one of these chronic medical conditions, as modern medicine has been able to prolong lifespan projections with medical management. However, extended quantity of life does not always correlate with ongoing quality of life. This is where awareness of PC is crucial in EM. George and colleagues published a PC screening tool specific to EM ( Fig. 2 ). This tool can be used as a general guide to identify potential PC needs in ED patients and demonstrates the breadth of disease conditions where PC may be beneficial.
Another useful tool in the ED is the tool offered by the Center to Advance Palliative Care. The tool identifies unmet palliative needs similar to the one by George and colleagues, such as frequent visits/bounce backs, uncontrolled symptoms, functional decline, and the surprise question. It also adds complex care requirement as a potential PC need.
A Road Map to Palliative Care Screening Tools for the Older Adult
Most ED clinicians are likely able to identify the presentations related to unmet PC consultations, but do not necessarily view them as opportunities to include PC. The following outline will provide a road map of these opportunities and demonstrate how this intersection between PC and EM can lead to collaboration and improvement in patient care overall.
Category 1: Frequent Visits
Two or more visits to the ED within the last 6 months can be indicative of uncontrolled symptoms and/or a medical care plan that is only temporizing the patient for brief periods as an outpatient. Review of symptom management, including meticulous review for polypharmacy in the geriatric population, and evaluation of goals of care (GOC) may address underlying issues related to these presentations. PC consultation or referral can support the ED clinician in this effort. Repeat presentations also present opportunities to collaborate with the patient’s PCP and specialists in a unified care plan. PC specializes in symptom management and the communication inherent to complex medical decision making and therefore is uniquely equipped to help address the underlying reasons behind bounce-back presentations for patients with serious illness.
Category 2: Uncontrolled Symptoms
Management of uncontrolled symptoms is an opportunity to address the symptom causing distress to the patient put in perspective how this acute exacerbation may be linked to the underlying trajectory of a serious illness. An example of this process is end-stage COPD, when patients present for acute shortness of breath, but continue to be oxygen- and steroid-dependent upon discharge with potential for concurrent impact to quality of life. Fig. 3 demonstrates the disease trajectory seen with organ failure, where the patient may improve from an exacerbation, but never return to his or her prior baseline. Symptom management using medication can be complicated by polypharmacy and resulting medication effects, as well as the possibility of compromised renal and hepatic function and/or decreased cerebral perfusion. Therefore, appropriate drug selection, judicious prescribing, and monitoring for adverse effects are of particular importance. An ED presentation for an uncontrolled symptom may also be an opportunity for collaboration with the patient and his or her family as well as the patient’s PCP to explore GOC and identify a plan moving forward for future management of exacerbations or anticipated disease sequelae. In addition to engaging pharmacist support when appropriate and available, EM physicians should consider a PC consultation where available. PC can assist with management of uncontrolled symptoms and polypharmacy, with expertise in utilizing medications in the setting of compromised end-organ function and with reviewing GOC and streamlining coordination of care across settings. Additionally, institutional policies and what is available on formulary may restrict what options are available to ED physicians; partnering with the ED pharmacist or available pharmacy support is generally advised. Interventional anesthesia or consultation services devoted to pain management may also provide additional support when appropriate, especially if PC consultation is not readily available. Finally, symptom management is complex and nuanced, with many important factors regarding the patient that should be taken into consideration.