Older people especially those living in residential aged care (residents) are particularly vulnerable group with complex care needs.  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. [1,2,5,14]
Handovers of care are particularly important to reduce risk of receiving inappropriate treatment.  Planning ahead for emergencies (emergency planning) is good practice and can improve the quality and safety of care. [4,15,16]
Emergencies may be completely unexpected but some may be anticipated during assessment.  Advance care planning documentation can reduce the risk of poor communication and unnecessary or unwanted invasive treatments in the event of an unplanned medical event. However, advance care plan completion rates remain low even for chronically ill older adults. For more information see Advance Care Planning.
Out-of-hours palliative care emergencies may require a transfer to a hospital, however, with an increasing focus on out-of-hospital palliative care, ambulance services around Australia have developed specialised roles. Extended Care Paramedics (ECPs) or Community Care Paramedics, with additional training and equipment for responding to palliative care needs. [17-19]
Many older adults with serious and life-threatening illness present to emergency departments (EDs) with an acute deterioration in health. [12,13] One review 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.  Despite the intensive use of these services, older adults transferring to acute care from a residential aged care facility (RACF) often have adverse clinical outcomes or die.  Strategies to address poor transition between services or engagement in palliative emergency and discharge planning are evaluated in the literature. They include early referral from ED to a palliative specialist appointment, early discharge planning, telehealth community support, electronic health records and education for caregivers on symptom management. The evidence is not strongly in support of any one intervention, all seem to show promising outcomes for quality of life for the individual and their family. [6,8-13]
The decision for a transfer to ED is often complex and influenced by many factors [1,2,5] including
- 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
- the perception of the quality of acute medical care in residential aged and in ED/hospital
- expectations of relatives and communication between relatives and residential aged care staff
- the availability of a GP particularly after hours
- the capacity (skills, confidence and staff numbers) of nursing staff to manage chronic conditions, acute conditions, end-of-life planning, and fall prevention
- adequate training of aged care staff particularly those working nights and on weekends.
Although early initiation of palliative care in the ED may contribute to less hospitalisation and help people remain at home at end-of-life, 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 to reduce hospital admissions. Advance care planning can identify preferred responses in an emergency. [3,4,6,7,12,13] To reduce the likelihood of readmission to acute care, several strategies that empower individuals and their carers in symptom management seem to be effective: education to improve knowledge of care and monitoring of change, and telephone support to help with symptom management. [8,9,11]
Overall the quality of the reviews included in this synthesis was good, with most reviews considered acceptable or of high quality.
Page updated 17 September 2021