Background Patients frequently present to the emergency department (ED) in their last year of life; improving goal-directed care and symptom management for these patients is important to promote patient dignity and autonomy and to reduce costs to the healthcare system.

Aims To determine the current proportion of patients presenting to a tertiary ED who have palliative care (PC) needs, and rates at which key indicators of good PC, particularly goals of care (GOC) clarification and symptom management, are documented.

Methods A retrospective case note analysis was undertaken across five different weekdays between April and June 2023 at a single tertiary Australian ED. The electronic medical record for adult ED presentations was reviewed and patients with PC needs were identified using the Supportive and Palliative Care Indicators Tool [www.spict.org.uk] and other clinical indicators. Case notes of patients with PC needs were screened against objective measures of good PC in the ED.

Results 108 patients were identified with PC needs over five days (12% of adult presentations) - of these, 87 (81%) were admitted and one patient died in ED. A further 14% died during subsequent hospital admission and 46% within 6 months. Seventeen patients (16%) were known to specialist PC prior to presentation. Of admitted patients, 24% were referred to the PC consult team. None discharged from ED were referred despite there being no formal barrier to this.

Whilst 72% of all admitted patients had a resuscitation status documented, only 10 patients (9%) had a documented comprehensive GOC discussion. For those bedbound at baseline, aged 90+, and those deteriorating with cancer, 27%, 21% and 13% had this conversation documented, respectively. Of admitted patients in these groups, 5%, 37% and 44% had their ceiling of care lowered during admission.

Pain scores were documented by nursing staff for 86% of patients; 48% had any mention of pain in medical notes. A third of patients with ongoing pain scores ≥7 were markedly under-prescribed analgesia, with a median time of four hours to any opioid analgesia for those charted it. More than 60% of patients with regular background opioid and 50% with regular benzodiazepine missed at least one dose. Documented assessment and management of other symptoms was scant.

Fourteen patients had documented wishes that they were not for life prolonging measures. Six of these (43%) received life-prolonging measures, nine (64%) were admitted with an average length of stay of 7.2 days (range 1–16), with seven of these admitted patients (78%) being listed for medical emergency team calls.

Discussion To the best of our knowledge, this study is the first to explore specific clinical management outcomes in patients with PC need in the ED. It has highlighted the challenges faced in identifying and appropriately managing this cohort, early in their journey within the acute medical system. Areas for improvement include identification of these patients and careful clarification of their goals and wishes, and assessment and management of pain and other symptoms in the ED.

Conclusion A significant proportion of patients presenting to ED have palliative care need. Novel initiatives are required to improve the identification of these patients and subsequent clinician response.