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Emergency Planning and Management

Key Messages

  • If implemented appropriately in aged care facilities, advance care planning can reduce emergency hospitalisations for residents. [1,2]
  • A current advance care plan can improve health management of older adults in the case of an emergency hospital admission. [1-4]
  • Strategies to improve discharge planning and community support for individuals and their carers may reduce readmission of older adults into acute care. [5-8]
  • Early initiation of palliative care or referral to specialist services in the emergency department (ED) may contribute to less hospitalisation and help people remain at home at end-of-life. [1-4,9,10]

 


Background

A palliative care emergency is a sudden and life-threatening change in a person’s condition. In this scenario, 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.
 

Evidence Summary

Emergencies may be completely unexpected but some may be anticipated during assessment. Advance care plans (ACP) can reduce the risk of poor communication and unnecessary or unwanted invasive treatments in the event of an unplanned medical event.
Planning ahead may be helpful for the following scenarios:

  • when travelling away from a local area,
  • a transfer from residential aged care facility to hospital,
  • a transfer by ambulance, or if triple zero is called in a crisis,
  • 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. [11]
Documentation of care preferences or the nomination of a substitute decision-maker can help to ensure that a person receives care in line with their wishes. [4] This is particularly important in end-of-life care where the goal is often quality of life rather than extending life. However, advance care plan completion rates remain low even for chronically ill older adults. This is attributed to poor literacy, procrastination or lack of discussion with a primary doctor. [2,4] The timing of discussions of advance care planning and who should initiate and review an ACP is still very much debated in the literature. In practice, these issues are highlighted as a barrier to effective and timely emergency care planning. [1,3,4]

Many older adults with serious and life-threatening illness present to emergency departments (EDs) with an acute deterioration in health. [9,10] 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. [1] Despite the intensive use of these services, older adults transferring to acute care from a RAC often have adverse clinical outcomes or die. [1] 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. [3,5-10]

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. [1-4,9,10] To reduce the likelihood of readmission to acute care, a number of 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. [5,6,8]


Quality Statement

Overall the quality of the reviews included in this synthesis was good, with most reviews considered acceptable or of high quality. 

 

 

Page created 19 June 2017
  • References

  • About PubMed Search

  1. Dwyer R, Gabbe B, Stoelwinder J, Lowthian J. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing. 2014 Nov;43(6):759-66.
  2. Dwyer R, Stoelwinder J, Gabbe B, Lowthian J. Unplanned transfer to emergency departments for frail elderly residents of aged care facilities: A review of patient and organizational factors. J Am Med Dir Assoc. 2015 Jul 1;16(7):551-62.
  3. Buswell M, Lumbard P, Prothero L, Lee C, Martin S, Fleming J, et al. Unplanned, urgent and emergency care: what are the roles that EMS plays in providing for older people with dementia? An integrative review of policy, professional recommendations and evidence. Emerg Med J. 2016 Jan;33(1):61-70.
  4. Oulton J, Rhodes SM, Howe C, Fain MJ, Mohler MJ. Advance directives for older adults in the emergency department: a systematic review. J Palliat Med. 2015 Jun;18(6):500-5.
  5. Bull MJ, Boaz L, Jerme M. Educating family caregivers for older adults about delirium: A systematic review. Worldviews Evid Based Nurs. 2016 Jun;13(3):232-40.
  6. Clegg A, Siddiqi N, Heaven A, Young J, Holt R. Interventions for preventing delirium in older people in institutional long-term care. Cochrane Database Syst Rev. 2014 Jan 31;(1):CD009537.
  7. Conroy S, Stevens T, Parker S, Gladman J. A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'. Age Ageing. 2011 Jul;40(4):436-43.
  8. Slack C. Best practice for after-hours hospice symptom management: A literature review. Home Healthc Now. 2015 Oct;33(9):482-6.
  9. da Silva Soares D, Nunes CM, Gomes B. Effectiveness of emergency department based palliative care for adults with advanced disease: A systematic review. J Palliat Med. 2016 Jun;19(6):601-9.
  10. DiMartino LD, Weiner BJ, Mayer DK, Jackson GL, Biddle AK. Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review. J Palliat Med. 2014 Dec;17(12):1384-99.
  11. CareSearch. Sharing Care [Internet]. 2017 [updated 2017 Feb 16; cited 2017 Jul 19].

Definition

Palliative medical emergencies include: airway obstruction, bowel obstruction, delirium, major bleeding, spinal cord compression and seizures. (CareSearch).

Searches

Final search

(airway obstruction[majr] OR superior vena cava syndrome[majr] OR airway obstruction[ti] OR superior vena cava syndrome[ti] OR intestinal obstruction[ti] OR bowel obstruction[ti] OR Intestinal Obstruction[majr] OR confusion[majr] OR confusion[ti] OR delirium[ti] OR Hemorrhage[majr] OR haemorrhage[ti] OR hemorrhage[ti] OR Seizures[majr] OR seizure*[ti] OR Hypercalcemia[Majr] OR Hypercalcemia[ti] OR acute pain[majr] OR breakthrough pain[majr] OR acute pain[ti] OR breakthrough pain[ti] OR emergenc*[ti] OR emergent[ti] OR urgent[ti] OR emergency treatment[majr] OR emergencies[majr] OR emergency medicine[majr] OR emergency medical services[majr])