Should a hospice patient who falls and hits their head at a nursing home be sent to the emergency room (ER) for a workup?

Should a Hospice Patient Who Falls and Hits Their Head Be Sent to the ER?

No, a hospice patient who falls and hits their head at a nursing home should generally not be sent to the ER for workup, as individuals receiving comfort/palliative/hospice care are explicitly excluded from standard fall evaluation protocols, and the focus should remain on comfort, dignity, and quality of life rather than aggressive diagnostic workup. 1, 2

Rationale for Non-Transfer

Guideline-Based Exclusions

• Hospice patients are specifically excluded from standard fall risk evaluation and prevention protocols according to stroke rehabilitation performance measures, which explicitly list "individuals receiving comfort/palliative/hospice care" as an excluded population from fall assessment and workup 1
• The 2023 World Society of Emergency Surgery guidelines emphasize that palliative management should focus on the patient's comfort and quality of life, preserving dignity rather than pursuing aggressive diagnostic interventions in end-of-life patients 1

Goals of Care Alignment

• Emergency and trauma surgeons must respect patient and family directives and collaborate with palliative care teams to ensure decisions align with the patient's wishes regarding end-of-life care 1
• Palliative care in the trauma setting aims to provide holistic support, alleviate suffering, and improve quality of life during remaining time, rather than pursuing potentially burdensome diagnostic workups 1

When ER Transfer May Be Appropriate

Symptom Management Needs

• Transfer to the ER should be considered only if symptoms cannot be adequately managed at the nursing home, such as uncontrolled pain, severe bleeding, or distressing neurological symptoms that require interventions beyond the facility's capabilities 1
• The decision should involve the palliative care team, patient (if able), and family to determine if transfer aligns with goals of care 1

Decision-Making Framework

• Ask: "Can this patient's comfort be maintained at the nursing home?" If yes, avoid transfer 1
• Consider: "Does the patient have advance directives (DNR/POLST) that would preclude aggressive intervention?" If yes, honor these directives 1
• Evaluate: "Would diagnostic workup change management in a way that improves comfort?" If no, workup is not indicated 1

Management at the Nursing Home

Immediate Assessment

• Perform focused neurological assessment including level of consciousness, pupillary response, and signs of increased intracranial pressure (severe headache, persistent vomiting, progressive lethargy) 2, 3
• Document fall circumstances and any witnessed loss of consciousness 2
• Examine for external signs of trauma such as scalp lacerations, hematomas, or skull deformities 2

Comfort-Focused Interventions

• Provide pain management with medications appropriate to the patient's goals of care 1
• Monitor for changes in comfort level rather than pursuing diagnostic imaging 1
• Engage palliative care team for guidance on symptom management 1
• Communicate with family about the fall, current status, and alignment with goals of care 1

Common Pitfalls to Avoid

• Reflexive ER transfer without considering goals of care: This subjects hospice patients to burdensome interventions inconsistent with their wishes 1
• Failure to involve palliative care team: These specialists have expertise in end-of-life decision-making that trauma and emergency providers may lack 1
• Not reviewing advance directives: DNR/POLST documentation should guide all decisions 1
• Pursuing diagnostic workup that won't change management: CT scans and other imaging rarely alter comfort-focused care plans 1