Of the literature retrieved pertinent to emergency planning and management, only two literature reviews in an aged care and palliative context were found. [1,2] Six reviews were in an aged care context but did not exclusively discuss end-of-life; [3-8] and four were in a palliative care context but not specific to older adults or an aged care. [9-12]
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. [2,7,12]
Emergencies may be completely unexpected. Some may be anticipated from the thorough assessment of a person’s disease and symptoms. A current advance care plan (ACP) can reduce the risk of poor communication and unnecessary or unwanted invasive treatments in the event of a change or decline in health.
Emergency health management
Many older adults with serious and life-threatening illness present to Emergency Departments (EDs) due to symptoms not with an acute deterioration in health. [9,10] Emergency medicine providers often have limited training or resources for palliative care which can result in individual and care preferences not being acknowledged in this setting. [9,10] 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.  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.  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. 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.  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 reduce admission to ED. [9,10] (see also Social Support/Volunteers/Workforce pages)
George et al.  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- 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.  found, in one study, that half of hospital admissions were via the ED and eligible for palliative care This suggests a need for better screening and referral or management. A significant number of these presentations to ED were due to ‘not coping at home’ and feeling safer in a hospital environment.  In these cases, many of the participants felt that an admission could have been avoided if they had adequate community services and support or their doctor had visited them at home. 
Acute care - early discharge planning
The systematic review by Conroy et al.  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. 
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.  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 only <44% cases had the older adult been reviewed by the General Practitioner before being transferred to acute care. 
Slack et al.  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.  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. 
Bull et al.  reviewed the benefits of educating family carers about symptom management as an intervention for unnecessary emergency admissions. This review focusses on the management of delirium which in older adults is considered a medical emergency as it contributes to a cascade of functional decline and increased mortality. Delirium is observed in up to 85% older adults receiving palliative care 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.  In the review by Clegg et al.  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 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.  The findings of both reviews are not conclusive. [3,5] While educating family carers seems to reduce the incidence of delirium, carer distress and the number of emergency admissions, the evidence is not robust.  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. 
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.  This is particularly important in end-of-life care where the goal is often quality of life rather than extending life. The timing of discussions of 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. [1,4,7]
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. 
Older adults are frequently managed for multiple comorbidities and cognitive and functional impairment. One review  notes that each year up to 75% residents in aged care facilities are transferred to a hospital emergency department for acute changes in health; much more than their community counterparts. Oulton et al.  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 literacy, procrastination or lack of prior discussion for the need for one with their primary physician. The reviews by Dwyer et al. [7,8] 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. If implemented appropriately for residents in aged care facilities, a current ACP can reduce emergency hospitalisations.
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. 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. 
- Increased understanding of why older adults present to emergency departments
- Specific screening tools for palliative care in the emergency department setting
- Identifying the needs of individuals and advocates for palliative care in emergency medicine
- Assessing if access to after-hours support reduces ED admissions
Page created 19 June 2017