Serious illness care in emergency departments: a systematic review of palliative care pathways for older adults with advanced noncancer conditions

Background: Older adults with advanced heart failure, chronic obstructive pulmonary disease, kidney disease, dementia, frailty, and non-cancer conditions reach emergency departments during deterioration, creating an opportunity for serious-illness care. Objective: This systematic review synthesized emergency-department palliative-care pathways for older adults with advanced non-cancer illness, emphasizing identification, communication, referral, transitions, and patient-centered outcomes. Methods: A PRISMA-aligned search framework covered PubMed, Scopus, Web of Science Core Collection, and the Cochrane Library from inception to July 2026. Original studies evaluating emergency-department screening, prognostic triggers, advance-care-planning interventions, palliative-care consultation, or post-emergency palliative follow-up were eligible when older adults with advanced noncancer conditions were included. Cancer-only studies were excluded. Owing to clinical and methodological heterogeneity, findings were synthesized narratively. Results: We include eighteen original studies. Screening pathways included the Surprise Question, P-CaRES, serious-illness criteria, and electronic-record mortality prediction. Communication pathways used brief negotiated interviews and nurse-led serious-illness conversations. System-level programs increased palliative-care referrals in some settings, whereas a large cluster-randomized implementation trial did not change admission, intensive-care use, revisits, hospice use, readmission, or mortality. Post-emergency nurse-led telephonic palliative care produced outcomes similar to specialty outpatient palliative care. Conclusions: Emergency-department pathways are feasible and increasingly scalable. The strongest pathway architecture combines automated or brief identification, focused goals-of-care communication, and dependable linkage to longitudinal palliative services.