Today ACEM joins with people and organisations the world over commemorating the UN International Day of Older Persons. It is an opportunity to reflect on the care provided in emergency departments to older persons and to consider how that care meets the needs of people seeking it.
‘The emergency department can be a very confusing and disorientating place for an older adult, especially if there is co-existent cognitive impairment or dementia,’ says FACEM Ellen Burkett, a member of the College’s Geriatric Emergency Medicine Section (GEMS) Executive.
‘There are a number of challenges for older adults in emergency departments – it can be a fast-paced environment, with lots of competing noise, rapidly changing visual stimuli and often multiple staff are involved in the care of one individual.’
Those staff may include doctors, nurses, hospital aids, radiographers, volunteers and allied health, Ellen says.
The growing need to understand the complexities of and comfortably deliver appropriate care to older persons in emergency departments has driven the release of updates to to two ACEM policies – End of life and palliative care in the emergency department (P455) and Care of older persons in the emergency department (P51).
‘There is no doubt that without advocacy for this group, their care can be suboptimal and this affects their care right through the hospital system and after discharge.
‘The Care of Older Persons Policy provides a framework to deliver high-quality care to older persons with the goal of improving outcomes in an often vulnerable cohort.’
The quality of care provided to older persons in the emergency department can directly impact on an individual’s outcomes.
‘It’s a pivotal point in time that determines the older person’s ability to return to independence versus transitioning to a life of ongoing care dependence,’ says FACEM Carolyn Hullick, Chair of GEMS.
‘Managing a 75-year-old car crash victim with multiple morbidities who is anticoagulated is very different to managing a 25-year old with similar mechanism of injury.
‘We are well trained to perform life-saving procedures, but in certain circumstances those procedures may not have benefit.’
‘Our challenge as practicing emergency physicians is to recognise when a patient may be on an end-of-life trajectory and have the confidence and skills to open a discussion about the goals of care and the limitations of medical intervention,’ Carolyn says.
Co-GEMS Executive FACEM Scott Pearson says the revised Palliative Care Policy provides a framework for those discussions.
‘With our ageing population – in society and our emergency departments – there are more frequent episodes of care that hinge around the extent of medical interventions.
‘Discussions with patients, family and whānau about the benefits and concerns of medical interventions and aligning management to the individuals’ goals of care are critical.’
He says a lot of time is spent acquiring technical expertise, but comparatively little time is spent developing communication skills in these complex goals-of-care discussions.
‘There is no perfect screening tool to detect the patient who is nearing the end of their life but adjuncts such as the “surprise question”, along with the Clinical Frailty Scale, can assist in this process, along with physician experience, SPICT and CrisTAL.’
He says it’s important to remember that these discussions may not be the start of the patient or family’s discussions.
‘It may be that the patient’s general practitioner has already started these discussions and the emergency department attendance is actually an opportunity to continue and advance this discussion.
‘Regardless, it important is that any discussions are documented so that the general practitioner or inpatient caregivers are well informed and are able to ensure that the care delivered is aligned to the person’s individual goals of care.’
The importance of communication is across the spectrum of the patient experience, Scott says.
‘Hopefully these policy updates will encourage emergency medicine staff to renew those relationships for the benefit of our patients.’
Updates to P51 and P455 are thanks to the work of many contributors. GEMS gives special thanks to palliative care-trained FACEMs Dr Bill Lukin and Dr Terry Nash (Queensland), Mark Webb (South Australia) and Dr Ian Rogers (Western Australia) for their specialist input to the palliative care policy, as well as Dr Eddy Strivens and the Australian and New Zealand Society for Geriatric Medicine Care of Older Persons review.
