The Role of Emergency Care in Patients with Advanced Dementia

The prevalence of advanced dementia (AD) is expected to increase dramatically over the next few decades.  Patients with AD suffer from recurrent episodic illnesses that frequently result in transfers to acute care hospitals.  The default pathway followed by the emergency physicians, internists and intensivists who see those patients there is prioritize disease-directed therapies over attention to the larger picture of advanced dementia.  While this strategy is desired by many families, some families prefer a different approach.  This essay examines the reason why this phenomenon occurs and offers suggestions for improvement.  Gaps in information and physician workload are important factors, but we argue that until physicians who see patients in emergency departments learn to pause first and ask “Why are we doing this?" they will revert to their comfort zone of ordering tests and therapies that may be unwanted.  A separate emergency palliative care pathway may be one solution.  Shifting the focus back to the larger picture of AD and away from the physiologic disturbance of the moment may alter the trajectory of care in ways that truly respect the wishes of some patients and their families.