Life-sustaining treatment preferences in older patients when referred to the emergency department for acute geriatric assessment: a descriptive study in a Dutch hospital

Daisy J M Ermers,Patricia J W B Van Mierlo,Yvonne Engels,Diana G Taekema,Marit P H Van Beuningen-Van Wijk,Frank H Bosch,Sonja C Stalpers-Konijnenburg,Evi Peters Rit

doi:10.1186/s12877-020-02002-y

Abstract

BackgroundIn many cases, life-sustaining treatment preferences are not timely discussed with older patients. Advance care planning (ACP) offers medical professionals an opportunity to discuss patients’ preferences. We assessed how often these preferences were known when older patients were referred to the emergency department (ED) for an acute geriatric assessment.MethodsWe conducted a descriptive study on patients referred to the ED for an acute geriatric assessment in a Dutch hospital. Patients were referred by general practitioners (GPs), or in the case of nursing home residents, by elderly care physicians. The referring physician was asked if preferences regarding life-sustaining treatments were known. The primary outcome was the number of patients for whom preferences were known. Secondary outcomes included which preferences, and which variables predict known preferences.ResultsBetween 2015 and 2017, 348 patients were included in our study. At least one preference regarding life-sustaining treatments was known at referral in 45.4% (158/348) cases. In these cases, cardiopulmonary resuscitation (CPR) policy was always included. Preferences regarding invasive ventilation policy and ICU admission were known in 17% (59/348) and 10.3% (36/348) of the cases respectively. Known preferences were more frequent in cases referred by the elderly care physician than the GP (P < 0.001).ConclusionsIn less than half the patients, at least one preference regarding life-sustaining treatments was known at the time of referral to the ED for an acute geriatric assessment; in most cases it concerned CPR policy. We recommend optimizing ACP conversations in a non-acute setting to provide more appropriate, desired, and personalized care to older patients referred to the ED.

Highlights

In many cases, life-sustaining treatment preferences are not timely discussed with older patients
Discussing and documenting life-sustaining treatment preferences is recommended in both primary and hospital care [16, 17]. These are based on recommendations for lifesustaining treatments defined in the Oxford Textbook of Palliative Medicine [18] and include cardiopulmonary resuscitation policy (CPR), admission to the intensive care unit (ICU) or coronary care unit (CCU), invasive ventilation, dialysis, defibrillation, and preferences regarding blood transfusion and antibiotics, or comfortfocused care
Study sample Between May 2015 and January 2017, general practitioners (GPs) and elderly care physicians referred a total of 501 patients to the emergency department (ED) for an acute geriatric assessment

Summary

Introduction

Life-sustaining treatment preferences are not timely discussed with older patients. Advance care planning (ACP) recognizes that advance directives (ADs) play an important role and can be used at these decision making moments [1, 2]. ADs include preferences regarding life-sustaining treatments, for example interventions like cardiopulmonary resuscitation (CPR), which need to be considered or undertaken in case of an emergency [3]. ACP is recommended when individual health conditions worsen, especially in the case of older people [2] where the decisional capacity may decline at some stage [5, 6]. ACP should be discussed timely with older people when decisional capacity still exists; an emergency is not an ideal situation to discuss ACP [7]. It is recommended that primary care physicians with longstanding doctor-patient relationships [8,9,10] timely discuss ACP with their patients [11]

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Results

Conclusion