Missed opportunities to introduce non-acute care pathways for elderly patients with palliative care needs

Dr Magnolia  Cardona-Morrell1, Ebony Lewis1, Dr Robin Turner2, Dr Hatem Alkhouri3, Dr Stephen  Asha4, Dr John  Mackenzie5, Dr Anna Holdgate6, Dr Sam Suri7, Dr Luis  Winoto8, Dr  Sally  McCarthy3,5, Professor Ken Hillman1,9

1The Simpson Centre for Health Services Research. The University Of New South Wales , Liverpool, Australia, 2School of Public Health and Community Medicine. The University of New South Wales, Sydney , Australia, 3Emergency Care Institute , Chatswood, Australia, 4St George Hospital Emergency Department , Kogarah, Australia, 5Prince of Wales Hospital Emergency Department, Randwick, Australia, 6Liverpool Hospital Emergency Department, Liverpool, Australia, 7Campbelltown Hospital Intensive Care Unit , Campbelltown , Australia, 8Sutherland Hospital Emergency Department , Sutherland , Australia, 9Liverpool Hospital Intensive Care Unit, Liverpool, Australia


Most chronically ill older people want to die at home but many still seek hospital services in their last year of life.


To typify elderly patients who may benefit from earlier transition to palliative care rather than long hospitalisation in acute care.


Prospective  analysis of cohort data for 65+ year-olds admitted to hospital via the Emergency Department in 2015-2016.


Of the 1,143 hospitalized elderly in the cohort, 48% were managed by four specialties: Geriatrics, Cardiology, Respiratory and Neurology. Only 5 patients (0.44%) had advance care directives. Ten percent died within six months of admission, 60% during the acute hospital stay. The following flags could have indicated time for transition to palliative care: relative to the survivors, the deceased were significantly more likely to: be older than 80 years (mean 82.5 vs 79.6, p=0.0003); be residents of nursing homes or in supported accommodation (20% vs. 6% of survivors, p<0.0001); suffer from at least two chronic illnesses (28% vs. 14%), p<0.0001); have been admitted to hospital at least once in the past year (73% vs. 57%, p=0.0012); have a do-not-resuscitate order (18% vs.3%, p<0.0001); and have length of stay longer than a week (mean LOS 9.6 days vs. 6.1, p=0.0163).


Communication of imminent death is complex and difficult, particularly in busy emergency departments. However, being alert to the presence of flags for imminent death could have resulted in shorter length of stay, earlier referrals to palliative care and less suffering. Further research is needed to clarify the reasons for underuse of palliative care services in the Australian context.


Comes from a background of Emergency Nursing and in 2014 completed a Master of International Public Health (MIPH) at the University of New South Wales.Her main interests are End-Of-Life Care, International Health and Non-Communicable Disease Prevention.