Opinion
End of life care in emergency settings IN RECENT years, the suitability of emergency departments (EDs) to meet the needs of an ageing population with complex conditions and comorbidities, and therefore significant palliative care needs, has come under question. Palliative care has been defined as holistic support provided to people with incurable, often long-term, conditions at any stage between diagnosis and death, as well as bereavement support for carers and family members (National Council for Palliative Care 2012). End of life care is a facet of palliative care (World Health Organization 2011). Older people account for two million ED admissions a year in the UK (Imison et al 2012) and 19.6 million a year in the United States (Albert et al 2013), and many present to EDs at least once in the last year of their lives. Such presentations are often distressing for patients and their carers, and challenging for emergency practitioners. In general, ED environments are not designed for older patients with palliative care needs, which ED staff may struggle to meet. In the authors’ experience, many emergency practitioners find accessing information about older patients difficult and, when patients are diagnosed with palliative conditions for the first time while they are in EDs, the experience is upsetting for all concerned. Older people can experience unexpected deterioration in, or emergency events unrelated to, their conditions, and they may have to be admitted quickly to hospital. There is, therefore, a need for role clarification, education and training of ED staff, as well as development of care plans designed for older patients, better resources and redesign of EDs. EMERGENCY NURSE
Alamy
Rebecca Blackwell and Corita Grudzen review how services for older patients in the UK and United States are changing
In the US, emergency departments for older people only are being introduced to improve end of life care
These issues have not been overlooked in the UK or US, but patients have been too little involved in service improvement. In the US in recent years, the role of EDs has been reviewed extensively and, in 2006, palliative medicine became a subspecialty of emergency medicine, whereby staff can receive dual accreditation. The ED model of care is being redesigned to meet the needs of older patients and innovations such as EDs for older people only, the direct admission of older people to palliative care wards and the development of palliative care support in EDs have been introduced in some areas of the country. Meanwhile, emergency practitioners across the US are publishing articles about the need to improve and increase the provision of palliative care services.
Developments in the UK have been slower but the care of older people is discussed in recent guidelines. The Department of Health (DH) (2013), for example, recommends changes to design specifications and staffing. Publication of the DH’s (2008) strategy for the care of older people led to the establishment of a national programme and an intelligence network for end of life care, and debate about the use of EDs by patients with palliative care needs. Initiatives in this area tend to focus on community-based strategies to reduce admission, but reports show that the ED is still the main gateway into hospital for older patients who need medical support for long-term or deteriorating conditions. The redesign of palliative care services should be based on the experiences of the patients themselves. In Australia, such experience-based co-design of EDs has enabled older people to help guide the care they need, and has equipped staff with the skills and resources to redesign their practice and behaviour accordingly (Bate and Robert 2006). All these innovations illustrate the same point: healthcare services must meet the needs of their populations and, when these needs change, the model of care adopted by these services must change too. Rebecca Blackwell is a PhD student at the Florence Nightingale school of nursing and midwifery, King’s College London Corita Grudzen is an associate professor of emergency medicine at the Icahn School of Medicine, Mount Sinai University, New York
References Albert M, Mccaig L, Ashman J (2013) Emergency Department Visits by Persons Aged 65 and Over: United States, 2009-2010. National Center for Health Statistics, Hyattsville MD. Bate P, Robert G (2006) Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Health Care. 15, 5, 307-310. Department of Health (2008) End of Life Care Strategy. DH, London. Department of Health (2013) Hospital Accident and Emergency Departments: Planning and Design Guidance. DH, London. Imison C, Poteliakhoff E, Thompson J (2012) Older People and Emergency Bed Use: Exploring Variation. The King’s Fund, London. National Council for Palliative Care (2012) Palliative Care Explained. www.ncpc.org.uk/palliative-care-explained (Last accessed: December 12 2013.) World Health Organization (2011) WHO Definition of Palliative Care. www.who.int/cancer/palliative/definition/en/ (Last accessed: December 10 2013.)
February 2014 | Volume 21 | Number 9 13
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End of life care in emergency settings IN RECENT years, the suitability of emergency departments (EDs) to meet the needs of an ageing population with complex conditions and comorbidities, and therefore significant palliative care needs, has come under question. Palliative care has been defined as holistic support provided to people with incurable, often long-term, conditions at any stage between diagnosis and death, as well as bereavement support for carers and family members (National Council for Palliative Care 2012). End of life care is a facet of palliative care (World Health Organization 2011). Older people account for two million ED admissions a year in the UK (Imison et al 2012) and 19.6 million a year in the United States (Albert et al 2013), and many present to EDs at least once in the last year of their lives. Such presentations are often distressing for patients and their carers, and challenging for emergency practitioners. In general, ED environments are not designed for older patients with palliative care needs, which ED staff may struggle to meet. In the authors’ experience, many emergency practitioners find accessing information about older patients difficult and, when patients are diagnosed with palliative conditions for the first time while they are in EDs, the experience is upsetting for all concerned. Older people can experience unexpected deterioration in, or emergency events unrelated to, their conditions, and they may have to be admitted quickly to hospital. There is, therefore, a need for role clarification, education and training of ED staff, as well as development of care plans designed for older patients, better resources and redesign of EDs. EMERGENCY NURSE
Alamy
Rebecca Blackwell and Corita Grudzen review how services for older patients in the UK and United States are changing
In the US, emergency departments for older people only are being introduced to improve end of life care
These issues have not been overlooked in the UK or US, but patients have been too little involved in service improvement. In the US in recent years, the role of EDs has been reviewed extensively and, in 2006, palliative medicine became a subspecialty of emergency medicine, whereby staff can receive dual accreditation. The ED model of care is being redesigned to meet the needs of older patients and innovations such as EDs for older people only, the direct admission of older people to palliative care wards and the development of palliative care support in EDs have been introduced in some areas of the country. Meanwhile, emergency practitioners across the US are publishing articles about the need to improve and increase the provision of palliative care services.
Developments in the UK have been slower but the care of older people is discussed in recent guidelines. The Department of Health (DH) (2013), for example, recommends changes to design specifications and staffing. Publication of the DH’s (2008) strategy for the care of older people led to the establishment of a national programme and an intelligence network for end of life care, and debate about the use of EDs by patients with palliative care needs. Initiatives in this area tend to focus on community-based strategies to reduce admission, but reports show that the ED is still the main gateway into hospital for older patients who need medical support for long-term or deteriorating conditions. The redesign of palliative care services should be based on the experiences of the patients themselves. In Australia, such experience-based co-design of EDs has enabled older people to help guide the care they need, and has equipped staff with the skills and resources to redesign their practice and behaviour accordingly (Bate and Robert 2006). All these innovations illustrate the same point: healthcare services must meet the needs of their populations and, when these needs change, the model of care adopted by these services must change too. Rebecca Blackwell is a PhD student at the Florence Nightingale school of nursing and midwifery, King’s College London Corita Grudzen is an associate professor of emergency medicine at the Icahn School of Medicine, Mount Sinai University, New York
References Albert M, Mccaig L, Ashman J (2013) Emergency Department Visits by Persons Aged 65 and Over: United States, 2009-2010. National Center for Health Statistics, Hyattsville MD. Bate P, Robert G (2006) Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Quality and Safety in Health Care. 15, 5, 307-310. Department of Health (2008) End of Life Care Strategy. DH, London. Department of Health (2013) Hospital Accident and Emergency Departments: Planning and Design Guidance. DH, London. Imison C, Poteliakhoff E, Thompson J (2012) Older People and Emergency Bed Use: Exploring Variation. The King’s Fund, London. National Council for Palliative Care (2012) Palliative Care Explained. www.ncpc.org.uk/palliative-care-explained (Last accessed: December 12 2013.) World Health Organization (2011) WHO Definition of Palliative Care. www.who.int/cancer/palliative/definition/en/ (Last accessed: December 10 2013.)
February 2014 | Volume 21 | Number 9 13
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