Project Summary
Alfred Health in partnership with Monash University has been awarded an ARIIA grant for their project ‘Emergency-Department-Initiated Palliative Care for Older People Transferred from Residential Aged Care: wrong time and place, or exactly what is needed?'
In Australia, one-third of older people living in residential aged care (RAC) are transferred to hospital in the last month of life and 20 percent of older people living in RAC will die in hospital.
The Emergency Department (ED) may not be traditionally thought of as the ideal setting for the initiation of palliative care, however early recognition of unmet palliative care needs can improve the quality of end-of-life care for patients and the experience of families. Previous studies have identified that ED clinicians may experience challenges integrating palliative care in the ED setting and palliative care services have limited involvement until a person is admitted to hospital. Further understanding of decision-making practices and experiences of ED clinicians (doctors and nurses) and consumers (older people living in RAC and their family members’) are needed to support the timely integration of palliative care into the patient journey.
Alfred Health and Monash University will trial an intervention designed to enhance recognition and response to unmet palliative care needs in older people transferred from RAC. This will support a systemic health system approach to palliative care engagement across the hospital and RAC sectors to improve end-of-life care delivery.
Project Outcomes
Background and Aims
In Australia, one third of older people living in residential aged care (RAC) are transferred to hospital in the last month of life and 20-percent of older people living in RAC will die in hospital. The emergency department may not be traditionally thought of as the ideal setting for the initiation of palliative care, however early recognition of unmet palliative care needs can improve the quality of end-of-life care for patients and the experience of families. Further understanding of decision-making practices and experiences of emergency department 42 clinicians (doctors and nurses) and consumers (older people living in RAC and their family-members’) are needed to support timely integration of palliative care into the patient journey.
What We Did
Alfred Health and Monash University trialled an intervention enable earlier access to palliative care services for older people presenting to the emergency department with unmet palliative care needs from residential aged care.
Outcomes
When an older person is transferred to the emergency department (ED) from a residential aged care facility (RACF) it takes time for ED clinicians to establish a course of action that aligns with the patients’ needs and preferences. It was common medical practice for emergency department clinicians to undertake investigations and commence a trial of treatment while a ‘full picture’ of the patient’s likely trajectory was established. Identifying and clarifying advance care directives was a time-intensive process and included locating the advance care directive and engaging, where possible, with the patient and/or family-members’ to understand their expectations and reach consensus on the best approach to care. It was identified that many residents who presented to the ED had selected a preference not to be transferred to hospital and to receive comfort care onsite in the RACF. ED clinician’ initiated palliative care referrals were often associated with concerns that the patient and or family had unrealistic expectations regarding the value and limitations of medical interventions and the need for further grief counselling. However, engagement in grief counselling and comprehensive end-of-life discussions exceeded existing resource capacity of both ED clinicians and palliative care services. Palliative care services in the hospital and the community were described as ‘over stretched’ and services were prioritised to serve patients who were either actively dying or were experiencing severe symptoms that were not responding to usual management. There is a gap in health service resourcing to support earlier engagement with patients and family-members who are experiencing death anxiety, existential distress and/or high levels of uncertainty about the end-of-life trajectory.
Recommendations
- Improve onsite 24/7 access to emergency department clinicians to support symptom management for people who are at the end-of-life and have a preference to receive comfort care in the residential aged care facility.
- Increase recognition of the psycho-social and emotional factors that influence hospital use at the point of deterioration and enhanced community-based supports to address death anxiety, existential distress and uncertainty amongst patient's and family-members.
- Increase availability and utilisation of grief counsellors for patients and or family-members who are recognised to have death anxiety, existential distress and/or high levels of uncertainty.
- Increase understanding of resident/family-members preferences for place of death and the reasons behind these preferences.
Impact on Aged Care and Workforce
- Initiation of 24/7 access to a telehealth service staffed by emergency physicians for patients who are specifically identified to be at the end-of-life, with a focus on comfort care.
- Further development of support for residential aged care staff with spiritual care and grief counselling services.
Next Steps
To support older Australians who have selected a preference to die in the community or in residential aged care, we are seeking funding to trial a 24/7 telehealth service staffed by emergency clinicians, using clinical practice guideline developed conjointly with palliative care specialists. This service would be used for patients who are specifically identified to be at the end-of-life, with a focus on comfort care.
In acknowledgement of the increasing palliative care presentations to EDs in Australia, we have received a grant to build a “Sacred Space” in the ED. This “Sacred Space” will be co-designed with older people, bereaved family-members, architects and clinicians. It will be trialled in 2025 to explore how the provision of a quiet, private and less clinical space in the ED supports the delivery of end-of-life care.
Contact Details of a Nominated Person
Name: Dr Bridget Laging
Email: b.laging@alfred.org.au