© Springer International Publishing Switzerland 2018Christian Nickel, Abdelouahab Bellou and Simon Conroy (eds.)Geriatric Emergency Medicinedoi.org/10.1007/978-3-319-19318-2_26
26. Palliative and End of Life Care for the Older Person in the Emergency Department
Imperial College NHS Trust, London, UK
KeywordsDementiaEnd of lifePalliativeEmergency department
“How people die remains in the memory of those who live on”
Dame Cicely Saunders (1918–2005) founder of the modern hospice movement
Global life expectancy for both sexes increased from 65.3 years in 1990 to 71.5 years in 2013, while the number of deaths increased from 47.5 million to 54.9 million over the same interval . In the developed world particularly, many deaths occur in the emergency department. In a 2011 survey, 43% of bereaved people said they thought that care for their loved one in the last 3 months of life was excellent or outstanding, but 24% said it was fair or poor—these findings suggest that end of life care for many people is just not good enough .
Older patients account for up to 25% of emergency department (ED) attendances, and some of these will spend their last hours in the ED . There is considerable palliative care needs among older people who attend EDs, but this need can be overlooked in an environment where the primary focus is resuscitation and saving lives [4, 5]. The development of major trauma centres in the developed world has seen a rise in the number of older patients who would have previously died from their injuries, surviving devastating traumatic injuries, often with a very poor prognosis. In such circumstances, decisions about palliation and end of life care need to be made in the ED. Furthermore, as people are living to a greater age with long-term conditions, the need for palliative care will increase, and clinical staff in the ED need to be equipped to care knowledgeably and with empathy for this group.
Palliative care was defined by the World Health Organization in 2002 as “an approach that improves the quality of life of patients and their families facing the problems 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” .
End of life care is defined as enabling and supporting the palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual and practical support .
Older patients are for the most part a vulnerable group, and decisions about their care should be influenced by quality of life rather than age.
Many older patients present with varying problems of a medical psychosocial nature where the presence of multiple comorbidities makes their assessment and management complex. Pathologies associated with ageing make the older person different to other patients, and these differences must be recognised if their needs are to be met in an individualised and timely way.
History taking is rarely straightforward and can be even more difficult where there is sensory impairment, dementia or delirium. Additional information and collateral history which is essential to forming an accurate overall picture may not be readily accessible, and time pressures mean staff can only focus on what appears to be the immediate problem.
Thus, there is a real need for expert knowledge, advocacy and expediency for those that are sick and dying. In addition, there is a great need for clinical staff to recognise and accept that in many situations, care may be more important than cure. It is not acceptable for older people to suffer unnecessarily due to poor recognition and under treatment of their problems and lack of access to palliative care.
Palliative and end of life care in the ED calls for a multidisciplinary response. Where a patient is dying, the goal must be to preserve the dignity and humanity of the person and to relieve suffering rather than expending valiant efforts to prolong a life which holds little or no quality for the person. When cure is not attainable and end of life approaches, the boundary between palliative care and emergency care needs to be more clearly defined. Many of the competencies that are needed to deliver effective care for people in the last few days and hours of life are generic. The professional capabilities that all doctors should possess to ensure the delivery of good-quality care across all specialties should include fundamentals such as the need to communicate effectively and empathise, as well as those more related to end of life care such as partnership and team working .
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26.2 Priorities for the Care of Dying People
Following a review of the controversial and now discredited Liverpool Care Pathway by Julia Neuberger in 2013 , the Leadership Alliance for the Care of Dying People in the UK published two documents in 2014, One Chance to Get it Right and an accompanying document for healthcare professionals, Priorities for Care of the Dying Person (LACDP, 2014b) [10, 11], which set out the approach to caring for dying people that health and care organisations need to adopt.
This approach is applicable regardless of place of death and lists five priorities for the care of dying people which focus on involving and supporting patients in their final days and hours. The five priorities focus on:
Recognising that someone is dying
Communicating sensitively with them and their family
Involving them in decisions
Supporting them and their family
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