Drivers of avoidable emergency department visits in older adults with multiple long-term conditions and palliative care needs: a qualitative survey across six care providers

Objectives Emergency department (ED) visits remain common among older adults with multiple long-term conditions, many of whom have palliative care needs. However, the ED environment is burdensome for these patients and often misaligned with their goals. This study explores experiences of shortcomings in outpatient care that drive ED use in this population to inform a primary care intervention.Method Qualitative content analysis of free-text responses from a survey of 100 physicians, registered nurses and nurse assistants working across primary care practices, home healthcare, EDs, geriatrics, ambulance services and advanced home healthcare in Stockholm.Results The analysis distinguished one overarching theme: ‘Delayed, fragmented palliative care in primary care settings contributes to ED visits’. This theme comprised two categories: (1) Palliative decision-making in primary care, including subcategories Recognizing palliative care needs and initiating care, and Including patients and families in shared decision-making; and (2) Delivery of palliative care at home, including sub-categories Care planning and symptom management at home, and Ensuring information transfer regarding patients’ preferences. Respondents described how these shortcomings led to crisis-driven ED visits that often conflicted with patients’ wishes to remain and die at home.Conclusion Delayed recognition of palliative care needs and the resulting delay in action are perceived as important drivers of avoidable ED visits in older adults with multiple long-term conditions. Strengthening generalist palliative care in primary care through targeted education, adequate resources, and access to specialist support are potential important components of an intervention aiming to reduce ED use and enable more proactive, person-centred, end‑of‑life care.