Comment améliorer la prise en soins des personnes âgées présentant un profil palliatif, admises en service d’urgence ?

Emergency services are increasingly being used by people with multiple chronic illnesses, who are frail, have difficulties in daily activities, and suffer from distressing symptoms. A quarter of emergency patients are aged 65 or older, with 15% being at least 80 years old. Nearly three out of four elderly patients will use emergency services in their last year of life, and half of them in their last month of life. Although palliative care and emergency care seem opposed, it is crucial to consider palliative care in emergency services due to the frequency of use by elderly people at the end of life. Emergency clinicians must make therapeutic decisions quickly for often critical situations. With an elderly and multi-morbid population, clinicians face important ethical questions, including evaluating the benefit-risk ratio of treatments. A major dilemma is deciding whether to continue life-prolonging treatments or initiate a palliative approach, which includes discussions on the intensity of care and the possible limitation of treatments. It is also crucial to respect patients' care goals and quickly assess their ability to understand their health status and treatment options. The palliative approach integrates ethical questions for end-of-life patients, but these questions are often difficult to address in emergencies due to time pressure and a lack of knowledge about the specific needs of frail elderly patients. So, how can we care for an elderly person with a potential palliative profile in emergency services? This thesis has made a significant contribution to addressing this question. In French-speaking Belgium, emergency professionals play important roles in the palliative approach, such as investigator, objectifier, palliative care provider, and care limitation decision-maker. The role of identifier is a key perspective for the future. It is essential to recognize these roles in a continuum of care and study them to highlight their complementarity with those of primary care actors. A consensus with a panel of experts has established palliative care recommendations adapted to the context and prioritized for implementation in emergencies. A major challenge remains the feasibility of their implementation, integrating elements of transition and continuity of care. Furthermore, nearly half of elderly patients admitted to emergency services have a palliative profile, and more than 70% see their health deteriorate over the year, with 37% resulting in death. The SPICT, "Surprise Question," and PICT tools are relevant for helping emergency professionals identify elderly patients with a palliative profile. For the future, it is necessary to test care models that integrate palliative care and geriatrics in emergency services. Additionally, it is important to study the allocation of resources needed to ensure quality care. Supporting the development of skills and knowledge is also crucial, particularly through the creation of training programs for clinicians. These programs should incorporate interprofessional and organizational collaboration.

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