Palliative Care in Older Adults

Clinical Relevance and
Considerations of Palliative
Care in Older A dults
a, b
Leah Bright, DO *, Bonnie Marr, MD
KEYWORDS
Palliative care Emergency medicine Older adults
KEY POINTS
The geriatric population is more likely to have serious and chronic illnesses that benefit
from palliative care involvement.
Recognition of disease processes amenable to palliative care should be standard practice
for emergency medicine physicians.
Understanding the unmet needs of the geriatric population amenable to palliative care can
change the trajectory of care in a positive manner.
INTRODUCTION AND EPIDEMIOLOGY
Emergency physicians routinely care for patients with serious illness. Geriatric patients
are more likely to have life-limiting illnesses and also suffer from a significant burden of
chronic disease.1 Since its recognition as an official subspecialty of emergency med-
icine (EM), palliative care (PC) has become better appreciated and its importance with
respect to caring for chronically ill persons recognized.
As the population in the United States continues to age, with baby boomers now
retiring at a rate of 10,000 individuals per day, a corresponding increase in Medicare
costs, especially among patients with chronic disease, has increased substantially.2
This concomitant increase in older adults, patients with chronic disease, and associ-
ated costs creates a health care system likely to benefit from the further involvement
and consideration of palliative care.
Furthermore, given that emergency departments (EDs) are seen as the safety net in
any health care system, many older adults with exacerbation of chronic disease are
seen in this setting. Often these patients, who increasingly have challenges accessing
primary care, never return to their baseline after these exacerbations.3 Moreover,
a
Emergency Medicine Department, Johns Hopkins Hospital, 1830 East Monument Street,
Baltimore, MD 21287, USA; b The Johns Hopkins Hospital, 600 N. Wolfe Street, Section of
Palliative Medicine, Blalock 359, Baltimore, MD 21287, USA
* Corresponding author.
E-mail address: [email protected]
Emerg Med Clin N Am 39 (2021) 443–452

https://doi.org/10.1016/j.emc.2021.01.007 emed.theclinics.com
0733-8627/21/ª 2021 Elsevier Inc. All rights reserved.
Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

ClinicalKey.es por Elsevier en abril 29, 2021. Para uso personal exclusivamente. No se permiten
otros usos sin autorización. Copyright ©2021. Elsevier Inc. Todos los derechos reservados.
444 Bright & Marr
these ED visits increase toward the end of life.4 Approximately 15% of people younger
than 84 years old visit the ED in the last 6 months of life, while 75% of people older than
84 year old visit the ED in the last 6 months of life, with half of these patients presenting
during their last month of life.1,4,5 For these reasons, it is imperative that PC practices
and interventions be considered a standard part of any EM physician’s
armamentarium.
Despite the rather recent recognition of PC in the ED, its value in addressing the
needs of the geriatric population in this setting has been demonstrated in the litera-
ture.6 Early PC intervention has been shown to decrease depression, improve quality
of life, and extend life expectancy by almost 3 months.7 It also has been shown to
decrease length of hospital stay.8 It is recognized not all EDs may have PC consultants
available; the involvement of the primary care physician (PCP), outpatient PC referral,
virtual PC consultations, and social work consultation may be a more feasible
alternative.
Incorporating PC into one’s practice in the busy environment of the ED may be chal-
lenging; however, it is important to recognize that EM physicians are often caring for
patients at a pivotal point in the trajectory of a chronic disease. These encounters offer
EM physicians the opportunity to intervene and introduce the support PC can offer pa-
tients and their families in the setting of serious illness. Therefore, the EM clinician has
to be facile at rapidly assessing for potential PC needs within the geriatric population.
It is important to distinguish PC from hospice care. PC focuses on specialized med-
ical care for people living with a serious illness with the goal of improving quality of life
for both the patient and the family.6 PC involvement can begin at any phase of a
serious illness, including at the time of diagnosis. Hospice, on the other hand, is
care in the last phase of a life-ending illness. The role of PC in treating the patient
and the family as a unit is especially important in geriatric patients, for whom there
is often significant caregiver involvement and fatigue. In addition, older adults are
more likely to have polypharmacy and under-recognized symptoms requiring careful
symptom management. Early involvement of PC should be considered a cornerstone
in the management of the older adults with chronic diseases presenting to the ED.6
Fig. 1 illustrates the difference in disease trajectory and continuum of support be-
tween early and late PC intervention.
INTERVENTIONS AND CONSIDERATIONS

Recognizing Opportunities for Palliative Care Involvement
PC is often associated with hospice, when in actuality, hospice is only a small part of
the spectrum of PC. The World Health Organization describes PC as “an approach
that improves the quality of life of patients and their families facing the problem asso-
ciated 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.”9 Life-threatening illnesses
include not only cancer but also congestive heart failure, end-stage liver disease
and renal disease, advanced chronic obstructive pulmonary disease (COPD), and
advanced neurocognitive diseases such as Alzheimer disease and Parkinson disease.
Recognizing that these chronic conditions, which are often debilitating and negatively
impact quality of life, are amenable to PC is paramount. The geriatric population is
likely to have at least one of these chronic medical conditions, as modern medicine
has been able to prolong lifespan projections with medical management.10 However,
extended quantity of life does not always correlate with ongoing quality of life. This is
where awareness of PC is crucial in EM. George and colleagues11 published a PC

Clinical Relevance and Considerations 445
Fig. 1. Reconceptualizing palliative care as a continuum of support. (Reproduced from:

Wang DH. Beyond Code Status: Palliative Care Begins in the Emergency Department. Ann
Emerg Med. 2017;69(4):437-43.)
screening tool specific to EM (Fig. 2). This tool can be used as a general guide to iden-
tify potential PC needs in ED patients and demonstrates the breadth of disease con-
ditions where PC may be beneficial.
Another useful tool in the ED is the tool offered by the Center to Advance Palliative
Care.12 The tool identifies unmet palliative needs similar to the one by George and col-
leagues, such as frequent visits/bounce backs, uncontrolled symptoms, functional
decline, and the surprise question. It also adds complex care requirement as a poten-
tial PC need.12
A Road Map to Palliative Care Screening Tools for the Older Adult
Most ED clinicians are likely able to identify the presentations related to unmet PC
consultations, but do not necessarily view them as opportunities to include PC. The
following outline will provide a road map of these opportunities and demonstrate

446 Bright & Marr
Fig. 2. Palliative care screening tool for emergency medicine. (Reproduced from: George N,
Barrett N, McPeake L, Goett R, Anderson K, Baird J. Content Validation of a Novel Screening
Tool to Identify Emergency Department Patients with Significant Palliative Care Needs. Acad
Emerg Med. 2015;22(7):823-837.)

how this intersection between PC and EM can lead to collaboration and improvement
in patient care overall.
Category 1: Frequent Visits

Two or more visits to the ED within the last 6 months can be indicative of uncontrolled
symptoms and/or a medical care plan that is only temporizing the patient for brief pe-
riods as an outpatient.4 Review of symptom management, including meticulous re-
view for polypharmacy in the geriatric population, and evaluation of goals of care
(GOC) may address underlying issues related to these presentations. PC consultation
or referral can support the ED clinician in this effort. Repeat presentations also present
opportunities to collaborate with the patient’s PCP and specialists in a unified care
plan. PC specializes in symptom management and the communication inherent to
complex medical decision making and therefore is uniquely equipped to help address
the underlying reasons behind bounce-back presentations for patients with serious
illness.
Category 2: Uncontrolled Symptoms

Management of uncontrolled symptoms is an opportunity to address the symptom
causing distress to the patient put in perspective how this acute exacerbation may
be linked to the underlying trajectory of a serious illness. An example of this process
is end-stage COPD, when patients present for acute shortness of breath, but continue
to be oxygen- and steroid-dependent upon discharge with potential for concurrent
impact to quality of life. Fig. 3 demonstrates the disease trajectory seen with organ
Fig. 3. Proposed trajectories of dying. (Reproduced from: L Lunney JR, Lynn J, Hogan C. Pro-
files of older Medicare decedents. J Am Geriatr Soc. 2002;50(6):1108-1112.)

448 Bright & Marr
failure, where the patient may improve from an exacerbation, but never return to his or
her prior baseline.13 Symptom management using medication can be complicated by
polypharmacy and resulting medication effects, as well as the possibility of compro-
mised renal and hepatic function and/or decreased cerebral perfusion. Therefore,
appropriate drug selection, judicious prescribing, and monitoring for adverse effects
are of particular importance.14 An ED presentation for an uncontrolled symptom
may also be an opportunity for collaboration with the patient and his or her family
as well as the patient’s PCP to explore GOC and identify a plan moving forward for
future management of exacerbations or anticipated disease sequelae.15 In addition
to engaging pharmacist support when appropriate and available, EM physicians
should consider a PC consultation where available. PC can assist with management
of uncontrolled symptoms and polypharmacy, with expertise in utilizing medications
in the setting of compromised end-organ function and with reviewing GOC and
streamlining coordination of care across settings. Additionally, institutional policies
and what is available on formulary may restrict what options are available to ED phy-
sicians; partnering with the ED pharmacist or available pharmacy support is generally
advised. Interventional anesthesia or consultation services devoted to pain manage-
ment may also provide additional support when appropriate, especially if PC consul-
tation is not readily available. Finally, symptom management is complex and nuanced,
with many important factors regarding the patient that should be taken into
consideration.
Category 3: Functional Decline

Assessment of functional status and evaluating for functional decline are essential
components of geriatric medicine and relate to the concept of frailty. The frailty syn-
drome has been described in different ways in the literature, but generally refers to
a set of phenotypic characteristics that are more likely to be present in an older adult
who is vulnerable to poor outcomes, frequent hospitalization, and overall mortal-
ity.16,17 Fig. 3 illustrates the functional status for the frail individual, which starts out
as low with ongoing losses over time until death. Resources within the ED may assist
with further evaluation if frailty or independent functional capacity concerns exist. Spe-
cifically, social workers may be helpful in the evaluation of dependence on caregivers
and understanding the home environment and any safety concerns. Physical therapy
and occupational therapy, if available, also offer insight into patient’s ability to com-
plete activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Insight into these factors may guide GOC discussions and help the physician under-
stand possible outcomes of the current ED presentation. Understanding a patient’s
baseline functional status and frailty is even more important when treatment options
are considered high risk with unfavorable outcomes, making shared decision making
even more of a priority.18 Reviewing GOC with prioritization of a patient’s personal
definition of what quality of life means to him or her may facilitate discussions
regarding disposition planning and referral to hospice when appropriate. PC teams
often are multidisciplinary and may include a social worker, chaplain, nurses, physi-
cians, nonphysician practitioners, pharmacists, and case managers, as well as insight
or support from therapy experts, making these teams ideal for the evaluation of func-
tional decline.
Category 4: Uncertainty about goals of care and caregiver distress

The ED often witnesses life-changing events, and critical discussions take place under
time-limited circumstances on a more frequent basis in the ED than in other health
care environments. The EM physician should feel confident about working to establish

a treatment plan that aligns with a patient’s GOC. If the patient is unable to participate
in the discussion, many communication tools exist to assist health care practitioners in
broaching GOC discussions with surrogate decision-makers for health care, including
from the Centers to Advance Palliative Care19 and VitalTalk. Individual states have
varying laws and policies for obtaining emergent consent of which the physician
must be aware. Complex communication needs surrounding GOC are an indication
for a PC consultation, which helps begin the process of engaging with the patient
and/or his or her family in exploration of GOC.
Caregiver distress is a significant indicator for PC involvement. According to the
Centers to Advance Palliative Care, improving the quality of life for both the patient
and the family is an important goal for PC.19 There are many different terms used to
Table 1
Palliative care resources
Resource Name Contents and Use Link

Palliative Care Fast Facts App for mobile phones and https://www.mypcnow.org/
resources on a Web site fast-facts/
Categories include medical
management of various
medical conditions for PC
and tips for difficult topic-
specific discussions
Center to Advance Palliative Categories include tools for Clinical tools:
Care (CAPC) dementia care, opioid https://www.capc.org/
Web site prescribing tools, and more toolkits/clinical-tools-
CME credit available for delivering-high-quality-
members of enrolled care/
institutions Online courses:
Some of the content requires https://www.capc.org/
registration/institutional training/
enrollment Integrating Palliative
Practices in the Emergency
Department Toolkit:
https://www.capc.org/
toolkits/integrating-
palliative-care-practices-in-
the-emergency-
department/
CAPC COVID-19 Web sitea Resources specific to https://www.capc.org/
emergency care of COVID toolkits/covid-19-response-
patients, including resources/
symptom management,
coping in a crisis, and
communication
Vital Talkª Resource for communication https://www.vitaltalk.org/
skills and guides, such as resources/
how to conduct a family
conference, disclose
serious news, and address
goals of care
Abbreviations: CME, continuous medical education; COVID, coronavirus disease.

a
This site has ongoing updates as new information becomes available.

450 Bright & Marr
describe the experience of caregivers of a chronically ill or disabled individual for an

indeterminate amount of time.18 These terms, such as caregiver fatigue, have vari-
able definitions in the literature and can include the physical, emotional, and social
dimensions of this experience, including sense of duty.20 At times, the circum-
stances and challenges of caregiving may lead to hospital admission for social rea-
sons to allow for a safe disposition. A PC consultation can be considered to offer
support to the patient and family as well as explore GOC as appropriate.20 If not
available, the interdisciplinary ED team, including social work, can participate in eval-
uation of caregiver distress and offer specific guidance related to this need.
Category 5: Suprise question/increasing complexity

The surprise question refers to whether the health care practitioner would be sur-
prised if the patient died within 12 months, as mentioned in step 2 of the palliative
screening tool in Fig. 2. Despite its inclusion in several palliative care screening
tools,11,12 a systematic review and meta-analysis by Downar and colleagues5 found
it does not perform well as a predictive tool for death, especially in noncancer illness.
The surprise question is not recommended as a stand-alone prognostic tool; howev-
er, it does encourage a broader perspective beyond the acute presentation at hand
to assess for unmet PC needs and may allow for consideration of hospice. An esti-
mated prognosis of 6 months or less in the setting of terminal illness can be sup-
ported by evidence of progression of disease, increasing clinical complexity, and
declining functional status, and, together with the patient’s GOC, helps demonstrate
potential eligibility for hospice.21 Hospice eligibility can be explored with the patient’s
primary physician of record, the medical director of the hospice of the patient’s
choice, resources available from Medicare, and the expertise of local social work
and case management support. Early consideration of hospice (when appropriate)
is further supported by the Choosing Wisely campaign from the American College
of Emergency Physicians, which states: “Don’t delay engaging available palliative
and hospice care services in the emergency department for patients likely to
benefit.”5 Overall, recognizing the downward trajectory of a chronic illness and
increasing complexity encourage the active assessment of PC and hospice needs
in the ED and building this intersection in the patient’s overall care earlier in their
course.
SUMMARY
Though PC has not historically been within the purview of EM, recognition of the
PC needs of the geriatric population should be part of standard practice and will
be of increasing importance as older adults will represent an increasing percentage
of the patients cared for in the ED based on current projections.10 EM is in a unique
position to facilitate early PC intervention, and thereby influence the overall trajec-
tory of care for these patients. Integrating PC into EM practice starts with an under-
standing of the disease processes amenable to PC. Understanding the often unmet
needs in the older population is also critical: frequent visits to the ED for chronic
disease exacerbation, challenges of uncontrolled symptoms, functional decline,
and the uncertainty around GOC.11,12 These criteria can serve as a roadmap for
the EM physician to guide partnership with the PC team in the management of
complex patients in order to optimize their care and quality of life. Table 1 lists
some additional PC resources available to EM physicians that can be used for
additional guidance.

CLINICS CARE POINTS
PC referral or interventions should be considered in older adults suffering from symptoms of

longstanding chronic disease, and not only at the end of life.
Interdisciplinary PC teams, including social workers, physical/occupational therapists, and
nurse case managers, should be engaged to provide an extra layer of support to
chronically ill patients and their families.
Caregiver burden should be considered by EM physicians when treating older adults
dependent on support for IADLs and ADLs, especially at the time of discharge.
GOC discussions can and should be conducted in the ED. Various tools are available to EM
physicians to assist with these difficult but important conversations.
DISCLOSURE
The authors have nothing to disclose.
REFERENCES
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ill, older adults presenting to the emergency department. Acad Emerg Med 2010;
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gency department in last month of life; most admitted to hospital, and many
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452 Bright & Marr
11. George N, Barrett N, McPeake L, et al. Content validation of a novel screening

tool to identify emergency department patients with significant palliative care
needs. Acad Emerg Med 2015;22(7):823–37.
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Clinical Relevance and

INTRODUCTION AND EPIDEMIOLOGY

Emerg Med Clin N Am 39 (2021) 443–452

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

INTERVENTIONS AND CONSIDERATIONS

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

Fig. 1. Reconceptualizing palliative care as a continuum of support. (Reproduced from:

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

Category 1: Frequent Visits

Category 2: Uncontrolled Symptoms

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

Category 3: Functional Decline

Category 4: Uncertainty about goals of care and caregiver distress

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

Resource Name Contents and Use Link

Abbreviations: CME, continuous medical education; COVID, coronavirus disease.

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

describe the experience of caregivers of a chronically ill or disabled individual for an

Category 5: Suprise question/increasing complexity

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

CLINICS CARE POINTS

 PC referral or interventions should be considered in older adults suffering from symptoms of

The authors have nothing to disclose.

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

11. George N, Barrett N, McPeake L, et al. Content validation of a novel screening

Descargado para Sebastian Moreno Quimbay ([email protected]) en CES University de

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