Palliative Care Utilization, Advance Care Planning, and Outcomes Among Older Adults With Cancer Presenting to the Emergency Department

BACKGROUND: Older adults with cancer frequently present to the emergency department (ED) with complex care needs, yet palliative care remains underutilized. We aimed to characterize palliative care utilization and advance care planning (ACP) among older adults with cancer presenting to the ED and examine associated outcomes. METHODS: We conducted a retrospective chart review of a random sample of 200 patients aged ≥ 65 years with cancer who presented to the ED at a tertiary academic center in 2022. Data included demographics, oncologic factors, ED encounter characteristics, palliative care utilization, ACP documentation, and outcomes. Analyses were descriptive, with exploratory associations evaluated using chi-square tests and logistic regression. RESULTS: Patients were older (mean age 74.3 years), and had frequent ED use, averaging 3.1 visits annually (SD = 1.9). Most were White (88.5%), male (52.5%), married (54.0%), and had a solid tumor malignancy (77.5%), with 28.5% receiving palliative-intent treatment. ED encounters frequently resulted in hospitalization (60.0%), with 18.3% of hospitalized patients requiring ICU admission. Palliative care consultation occurred in 2.5% of patients in the ED and 16.5% overall. ACP documentation increased from 65.5% at presentation to 75.0% following the encounter, largely driven by new MOLST completion and changes in code status. Mortality was high, with 24.4% dying during hospitalization and 49.0% within 6 months of the ED encounter. Among those who died within 6 months, 66.3% had not received palliative care consultation. In exploratory analyses, palliative care consultation, intensive care interventions, and ED visit frequency were associated with mortality. CONCLUSIONS: Older adults with cancer presenting to the ED experience high rates of hospitalization, intensive care use, and short-term mortality, yet palliative care remains underutilized. Although ACP documentation increased during acute care encounters, these changes often occur with clinical deterioration. The ED offers an opportunity to identify unmet palliative care needs and facilitate earlier integration.