How ERs fail older patients

ERs are built to take on all patients of all ages, but seniors may wonder if they’ve come to the wrong address. @NightshiftMD has the details.

Emergency departments are the usual destination for older patients in need of treatment. For the sick and injured, the ER is supposed to be a beacon of hope. For seniors, it's becoming a place of futility. That trend has started in Canada, but is well established in the U.S.  

If you don't believe our population is aging, visit an ER.  South of the border, Americans age 65 and older make over 21 million visits a year make a visit to the ER. One out of every six patients who come to the ER is of retirement age and older.

In Canada, after infants, seniors make up the largest group of patients, many of them near the end of life.  One study found that half of all older people go to emergency at least once in the last month of life.  And when they get there, they find a growing clash between the treatment that ERs offer and what patients want.  

The cliché is that families demand lifesaving treatment. But lately, we're starting to see a new trend:  doctors pulling out all the stops, and patients and families wishing they would just stop.

I see lots of frail, older patients with four, eight, even 10 diagnoses.  Some have trouble breathing, others have dehydration or pneumonia.  Some need surgery.  Our instinct is to start aggressive treatment.  We send some of these patients to the intensive care unit. At first, patients and families might like the feeling something is being done. Eventually, many don't like or want it.  

Just recently, I saw a patient with dementia who was sent in by a doctor for some tests.  Obligingly, I ordered a CT scan.  Next thing I know, the patient's substitute decision maker called from out of town to say she wanted to cancel the tests.  I had tried to reach her and had left a message.  The thing is, I had assumed incorrectly that the doctor who sent the patient to the ER knew the family's wishes.  I cancelled the tests, and the family took the patient home.  That story opened my eyes.

Why is there such a clash of opinions? Patients and families need to understand that most people like us went into the health professions to do things like cracking open chests, setting broken bones, shocking hearts and dissolving blood clots that cause strokes.  That's what's known as acute medicine.  At least privately, many health professionals admit they didn't go into medicine to treat chronic diseases like dementia, heart failure and cancer. And yet, that is what older patients have.

Expectations are another factor. Health professionals who shock hearts and take patients to the operating room are considered heroic; those who don't are considered weak and even incompetent.  

Another factor in the ER is the need for speed. A wise colleague once told me it takes 10 minutes to put an older patient with dementia on a ventilator, but it can take hours to talk with a family about death and try to figure out what the patient really wants.

Things could be different for older patients. The alternative is to make the ER a place where patients who don't benefit from lifesaving care get less of that and more comfort.  There's a movement to make palliative care an essential part of the mission of the ER. The aim of palliative care is to improve the quality of life by managing pain and other symptoms. Hospitals in several states across the U.S. have brought palliative care services directly into the ER. The triage nurse screens patients to identify those who might benefit from comfort measures. Some have built rooms in the ER that are separated from the rest of the department and are better for quiet discussions.  Around 150 board-certified ER physicians in the U.S. have become certified in palliative care.

I hope we see similar changes in Canada. There are family doctors in Canada who do both palliative care and emergency medicine, but they're an anomaly.  I'd love to see more ER physicians take this on.  With tight provincial budgets, I doubt we'll see ERs retrofitted to do more palliative care.

I'm keeping my eye on Eastern Health in Newfoundland.  Last year, the health region began implementing a policy to ask every patient admitted to hospital – regardless of age – their end of life wishes. I like that idea, but we should not wait until people are admitted to the hospital.  Each of us should figure out what kind of care we want near the end of life.  That would take some of the guesswork and the stress out of visits to the ER – for everyone.

Palliative care services remain woefully inadequate in Canada.  Without improvements, it will be impossible to deliver a more compassionate option, and the conflict between patients, families and people like me will continue to widen.


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