Considerations of Intersectionality for Older Adults with Palliative Care Needs in the Emergency Department: An Integrative Review

Abstract

Purpose of Review

We sought to identify current interventions, research, or non-research evidence that has direct or indirect consideration of intersectionality in the care of older adults in the emergency department (ED). An integrative review informed by Crenshaw’s Theory of Intersectionality was conducted in accordance with Whittemore and Knafl’s five-stage methodology. A rigorous review process determined appropriateness for inclusion, and articles were analyzed for areas related to direct or indirect relationship to intersectionality.

Recent Findings

Older adults aged 60 and above in the United States (US) account for more than 20% of ED visits annually, and half of older adults will visit the ED in their last year of life. There has been a growing focus on adapting the ED to meet the palliative care needs of older adults, but relatively little consideration has been given to older adults’ intersectional identities.

Summary

Six articles were identified that provided indirect insights into the status of intersectionality in ED-based palliative care for older adults. Two areas of interest were identified: (1) intersectional elements or reference to such elements embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis. This review highlights areas for future research along with recommendations for adopting an intersectional framing into commonly used methodologies.

Introduction

The use of the emergency department (ED) by older adults is on the rise globally, particularly for those with palliative and end-of-life care needs [1–3]. Palliative care is an approach that enhances the quality of life of patients and their families in the face of problems associated with life-threatening illnesses through preventing and relieving suffering by identifying early, assessing accurately, and treating appropriately, pain and other physical, psychosocial, or spiritual problems [4]. However, due to compounding systematic barriers within approachability, acceptability, availability, affordability and appropriateness of care [5], the outcome is often reduced availability of and access to palliative services, meaning many people do not receive much needed palliative care [6]. This goes some way to explaining why half of older adults have at least one ED visit in the last year of life [7], and about 40% of people have at least one ED visit in the final weeks of life [8].

Specific reasons for admissions are varied, and often driven by a complex compounding of physical, psychological, and social challenges [8]. As care in the ED is often centered around providing life-sustaining interventions, older adults with palliative care needs may receive care that is not in line with their goals or wishes at the end-of-life [9–13]. In particular, where palliative care aims to provide end-of-life care in line with a person’s wishes and through a holistic lens, the fast-paced environment of the ED means it can be less likely that care approaches assess the identify of older adults from a perspective of intersectionality.

Intersectionality is a theoretical framework that positions social identities as existing on a hierarchy of social power. This is not independent but rather together influences individual experience [14, 15]. There are a number of core features to this approach with a priority in exploring multiple and inter-related social identities, a deliberate move away from homogeneity of populations in order to understand lived experience and an acceptance of the fluidity and social construction of identity embedded in structural power dynamics [16, 17]. The benefits of an intersectional framework when examining health disparities include a conceptual framework and language to explore how multiple social identities can influence health whilst also prioritizing complex social inequalities [18].

Intersectionality also highlights how macro power structures interconnect to produce health inequalities that extend beyond the individual. It can potentially generate population-level policy and practice interventions that can also impact on historic inequalities and provides a more nuanced analysis by reporting beyond, for example, simple categories like race/ethnicity and age. There remains limited intersectional work related to age since this is rarely included in such analyses [19, 20]. This is in spite of evidence of ageism within healthcare leading to poor health outcomes [21] and evidence of ageism specifically within the ED [22, 23].

Currently, nearly one in four older adults are members of underrepresented racial and ethnic groups, and older adults are expected to account for 21.6% of the population in the US by 2040 [24]. While there has been an increase in the literature examining end-of-life outcomes among diverse older adults [25–27], few studies have examined intersectional identities as they relate to quality of end-of-life care. Instead, health care provision of older adults often lacks intersectional considerations [19]. This is unfortunate, as disparities can become compounded in old age due to the cumulative impacts of advantages and disadvantages over the life course, and generalizations about “old people” can result in research or interventions that decrease the quality of life for some older adults [28].

When providing care for older adults in the ED, despite some remarkable efforts, it can be challenging for ED staff to assess and meet their often highly complex needs [29]. There have been efforts to address the various needs of older adults in the ED, with some innovative recommendations and changes in practice, such as the seminal work of Hwang [30] regarding redesign of the ED to meet the needs of older adults, reflecting principles of universal design. For example, non-slip floors, special lighting, handles on walls, large font print information. Other examples include frailty units, volunteer programs, music therapy and relaxation tools [30]. However, these interventions are not common practice, and do not necessarily address palliative care needs. Further, exploration of staff attitudes towards older people with palliative care needs also shows some degree of bias and discrimination, e.g., assuming admission is the care goal, or exclusion from decision-making processes [29]. Given the assumptions often made about older adults purely based on age, including negative stereotypes, and tendency to paternalistic attitudes, other factors would only compound challenges to holistic care, particularly in the ED’s fast-paced and challenging environment [21]. Further, the history, background, needs, interests and culture of older adults are prominent factors that should be considered. This all highlights the need for an intersectional perspective on older adults in the ED with palliative care needs.

Given the changing demographics of the older population, the frequency of end-of-life visits to the ED, and the importance of taking a holistic approach towards the palliative care of older adults, this integrative review aims to identify the following: To what degree is the concept of intersectionality directly or indirectly considered and addressed in the literature about older people with palliative care needs in the emergency department?

Methods

Guiding Methodological & Conceptual Frameworks

Our integrative review follows the five-staged methodology outlined by Whittemore & Knafl: (1) Problem Identification; (2) Literature Search; (3) Data Evaluation; (4) Data Analysis; and (5) Presentation [31]. During Stage 3 (data evaluation) we additionally drew on the resources of the Johns Hopkins Evidence-Based Practice (JHEBP) Model, as it uniquely includes consideration of integrative reviews and provides a guide for research and non-research evidence sources [32]. The work was theoretically underpinned by Crenshaw’s Theory of Intersectionality [33]. During stage 4 (data analysis) we had to use a modification to Whittemore & Kanfl’s suggested analytical process due to a lack of direct intersectional framing within the identified papers [31]. Instead, we analyzed indirect aspects of the papers from a perspective of areas of interest rather than broad themes, and included study design and methodology, rather than study findings. We reflect on the impact, benefits and challenges of integrating these approaches collectively and individually in our discussion.

Search Strategy

To answer our enquiry, a comprehensive review of the literature was undertaken across PubMed, Embase, Cochrane, CINAHL, and PsycInfo databases. Our main search terms were older adults AND palliative care AND emergency department AND intersectionality. For the full search strategy including search term synonyms and results please see Appendix 1. We included the filters English language, publication date (from 2012 to 2023), and age groups (Aged 65 years & older). Our initial search yielded 398 articles, which were uploaded to Covidence (a web-based platform supporting systematic reviews). After 62 duplicates were removed, 336 articles remained for title and abstract review. To guide our decision-making for abstract review, we used the following inclusion criteria: (1) based in the ED, (2) focused on delivery of care, (3) acknowledgment/discussion or reflection on tailoring of care to needs beyond age, (4) research evidence all levels, (5) non-research evidence (protocols, opinion pieces, editorials), (6) systematic review with or without meta-analysis if on the topic & providing new information, (7) meta-synthesis if on the topic and providing new information, (8) palliative care (including hospice/end of life/terminal), (9) patients aged 65+. The exclusion criteria were: (1) prevalence of visits, (2) reasons for visits, (3) ED as an outcome (e.g., no mention of what occurred in the ED), (4) non-research evidence review papers, (5) caregiver/family focus.

All abstracts were reviewed by two people and any conflicts were discussed and resolved by the authors collectively. A total of 318 articles were excluded leaving eighteen articles for full text review. During our full text review, we were unable to identify any articles that explicitly considered the concept of intersectionality, therefore, to be considered for inclusion, articles had to make a direct or indirect reference to intersectional elements of a person’s identity that move beyond standard descriptors. Standard descriptors included: race, gender/sex, age, diagnoses. As before, all manuscripts were reviewed by two people (all authors participated in this process), with group discussion and consensus on any disagreements. At the end of the process six articles were selected for review; five from the process outlined above, and one additional article identified and included via a hand-search for an article based on a conference abstract found within the main review. The full process is depicted in Fig. 1 (PRISMA Flow Diagram) [3].

Fig. 1.

PRISMA Flow Diagram

Data Evaluation & Analysis

All members of the authorship team performed the extraction shown in Table 1 following the JHEBP model [32]. Data analysis was conducted by all the authors through iterative rounds of discussion and review, and as stated, due to a lack of direct focus on intersectionality, we were unable to analyze for themes, and instead considered areas of interest relating to indirect reference to intersectional factors within the study tools and study populations. The level and quality of the included studies is provided in Table 1, but we have not listed study limitations, as these are outside of the scope of interest for this article.

Table 1.

Evidence Summary [3, 34–3,8]

Author, date, and title	Type of Evidence	Population, size, & setting	Direct or Indirect Considerations of Intersectionality	Measures used	Evidence level & quality
Bone, et al. (2019). Factors associated with older people’s emergency department attendance towards the end of life: a systematic review.	Systematic review of nonexperimental studies only, without meta-analysis.	Population: Older adults ≥ 65 years (more than 90% of the sample is over 65, or the mean age is over 70). Size: 21 studies (N = 1,565,187 older people) Settings: USA (N = 17 studies), UK (N = 2 studies), France (N = 1 study), and Australia (N = 1 study).	Indirect -consideration of impact of sociodemographic factors (gender; ethnicity; age; rurality; education; income; marital status), service-related factors. -There was a higher ED attendance among those from non-white ethnicities, males, living in rural areas, and without cancer conditions, suggesting that end-of-life care should be addressed in a more equitably manner. -Enhancing access to palliative care and hospice for non-cancer populations and non-white ethnicities could also reduce the inequalities at the end of life.	N/A	Level III Good quality.
Hill, et al., (2022). Emergency and post-emergency care of older adults with Alzheimer’s disease/Alzheimer’s disease related dementias.	Quantitative Descriptive study using aggregate analysis of Medicare claims data.	Population: community-based sample. Size: 29,626 pts AD/ADRD, 317,046 pts non AD Setting: USA.	Indirect - Discussion included reference to additional factors that can influence palliative care needs of persons with dementia: (1) numerous barriers to receiving a dementia diagnosis, including denial, stigma and fear, lack of knowledge, normalization of symptoms, preserving autonomy, lack of perceived need, unaware of changes, lack of informal network support, carer difficulties, problems accessing help; (2) communication and shared decision-making.	Medicare’s Master Beneficiary Summary File-Input, Output, Vital Status, Hospice Healthcare utilization in the 12 months following the ED visit.	Level III High Quality.
Kabell Nissen et al., (2022). Prognosis for older people at presentation to emergency department based on frailty and aggregated vital signs.	Quantitative Single-center prospective observational cohort study.	Population: Patients ages 65≥ Size: 2250 patients Setting: Emergency department, University Hospital Basel, Basel Switzerland.	Indirect: -noted in discussion section that measure without threshold may be stronger as shared decision-making includes patient concerns and values that are not well-accounted for when measure threshold is used.	National Early Warning Score (NEWS). Clinical Frailty Scale (CFS). Frailty adjusted Prognosis in ED (FaP-ED).	Level III High Quality.
Schmucker, et al., (2021). Data from emergency medicine palliative care access (EMPallA): a randomized controlled trial comparing the effectiveness of specialty outpatient versus telephonic palliative care of older adults with advanced illness presenting to the emergency department.	Quantitative Multicenter, parallel, two-arm randomized controlled trial.	Population: Patients ages 50 > with advanced cancer, or end-stage organ failure. Size: 500 people from 18 sites. Setting: Emergency departments across the US.	Indirect -Consideration of impact of geographic location, birth country, residency status, and language in addition to age, race, ethnicity, and diagnosis. -Tools used in study provide data for a holistic interpretation of the patient’s status, taking into consideration quality of life and loneliness, along with function and symptom burden. Provides insights in study participants including family dynamics, analysis considers intersectional elements impacts on core study outcomes.	-Self-reported demographics, -Quality of Life: Functional Assessment of Cancer Therapy-General (FACT-G); -Loneliness: 3-item UCLA Loneliness Scale. -Symptom burden: Edmonton Revised Symptom Assessment Scale.	Level I High Quality.
Stoltenberg, et al., (2022). Developing a novel integrated geriatric palliative care consultation program for the emergency department.	Discussion / Service Improvement Model development using consensus approach	Population: Consensus group of experts in geriatric emergency medicine and ED-based palliative care. Size: 23 Setting: USA.	Indirect -Responds to awareness that ED care may not align with older adult’s goals, values, including those with life-limiting illnesses −4 Core clinical tasks: (1) focused, multidimensional assessment including physical symptoms, psychosocial issues, and an adaptation of the 4 M framework of Age-Friendly Health Systems with mobility, mentation, medications, what matters most; (2) focused serious-illness conversation; (3) integrate high-yield palliative care and geriatric recommendations within the specific context of the ED focused on symptom management, medications, and mitigating iatrogenic harm; (4) connect pts to appropriate palliative care and geriatrics services within hospital and community.	N/A	Level IV Good quality.
Wu, et al., (2013). Effects of initiating palliative care consultation in the emergency department on inpatient length of stay.	Quantitative Intervention study using pre-post multivariate analysis to determine effect on length of stay (LOS)	Population: Patients with palliative care consults at CPMC-Pacific and Davies. Size: 1435 patients Setting: ED at California Pacific Medical Center (CPMC)-Pacific and Davies campuses in San Francisco, CA, USA.	Indirect -Study focus is around providing care that matches the patient wishes and preferences -Study highlights that this focus is unusual for ED care for adults with palliative care needs (all participants mean ages were > 65).	All Patient Refined Diagnostic Related Group (APRDRG) risk of mortality (ROM) and severity of illness (SOI).	Level II Good Quality.

Findings

We identified six articles providing insight into intersectionality in ED palliative care for older adults (Table 1). Articles reflected research from Switzerland (n = 1), the UK (n = 1), and the US (n = 4). As per the JHEBP appraisal tools, articles were varied between levels I-IV, and with a quality rating of good to high [32]. There were a range of study designs, including systematic review, randomized controlled trial, retrospective and prospective descriptive studies, and a model development paper. The angle of focus for ED-based palliative care for older adults varied, and included prognostics [34], palliative and geriatrician consultation [35], Alzheimer’s disease [36], causes for ED attendance [37, 38], and new care model creation via expert consensus [39].

Intersectionality was not an intentional framework or direct focus in any of the articles, however all articles contained indirect consideration of some factors beyond the traditional demographic markers commonly used. Based on the guiding theoretical framework of intersectionality, we identified areas where these papers tentatively describe how systems of inequality may intersect based on gender, race, sexual orientation, class, disability and other forms of discrimination to produce particular outcomes and consequences. We identified two areas of interest to this end: (1) intersectional elements or reference to such elements, embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis.

Intersectional Elements Indirectly Embedded Within Studies

Bone et al. [37] present findings in their systematic review acknowledging a number of sociodemographic factors, including gender, ethnicity, age, rurality, education, income and marital status that may impact ED attendance. Their data suggested high attendance and inequality, particularly in non-white populations in accessing palliative care and hospice support. Hill et al. [36] attempts to explore some of the influencing factors related to people living with dementia visiting the ED and access to palliative care. They acknowledge the stigma associated with dementia and explore barriers to receiving a dementia diagnosis including fear, social isolation and communication challenges. There was, however, a limited attempt to examine inequality in relation to age, gender or race within their analysis or discussion and how this intersects to potential positioning and experience of ED outcomes for people living with dementia. Kabell Nissen et al. [34] in developing and internally validating the frailty adjusted prognosis in ED tool (FaP-ED) do acknowledge the wider importance of a multi-faceted approach to older frail people. They present this tool as complementing other measures like the Comprehensive Geriatric Assessment to explore shared decision-making, communicate uncertainty and examine concerns and values that impact on choice preference. This presents a positive attempt at positioning personal choice and active decision-making in relation to validating a tool especially given the tight remit of the paper’s aims and objectives. Schmucker et al. [38] reports on aspects of their data set from the Emergency Medicine Palliative Care Access trial focusing on baseline demographic and quality of life (QoL) data, identifying the association between illness type and baseline QoL and finally the baseline relationships between illness types, symptom burden and loneliness. There is a consideration of the impact of geographic location, birth country, residency status and language, as well as age, and race, ethnicity and diagnosis. There is an attempt to provide a more holistic approach to a patient’s status including wider contextual elements such as loneliness and family dynamics. Stoltenberg, et al. [39] describes a brief history of geriatric and palliative integration in EDs and through a stakeholder and expert conference they developed a consensus related to new models of integrated care between geriatric and palliative medicine. The new model focused on multidimensional assessment, an adaptation of age-friendly frameworks and serious-illness conversations. Furthermore, within the ED there was a spotlight on symptom management, medications and preventing iatrogenic harm and referral to appropriate palliative or geriatric services in hospital and community settings. There was a focus on the patient context including seeking information from family, however, there was limited acknowledgement of structural inequality and how the intersection of race, age or gender, for example, could impact on new models of care. Wu et al. [35] examined whether there was a decrease in length of stay for inpatient admissions after palliative care consultation initiated in the ED compared with those initiated after hospital admission. The study attempted to explore providing care that was in tandem to patient’s choice and preferences and highlights the novelty of this approach when applied to palliative care needs in the ED.

The Challenges of Adapting Quantitative Methodologies to Incorporate Variables and Approaches that Would Allow for Intersectional Analysis

Another area of interest was related to the methodological approaches of the papers in this review. Four papers were quantitative in design, one was a systematic review and one a discussion paper (Table 1). There was a lack of methodological diversity with no qualitative or mixed methods approaches. Quantitative approaches consisted of either descriptive studies [36], prospective observational cohort studies [34], data mining from a randomized control trial [38] or an intervention study [35]. The majority of studies in the included systematic review were retrospective observational/cohort studies [37]. Certain methodological approaches lend themselves to explore a more intersectional perspective with a call for more mixed methods approaches [40]. To incorporate a more intersectional approach to quantitative analysis, the papers in this review need to avoid an assumption of homogeneity across intersections related to outcome and process and situate their discussion within a context of social power [18]. Intersectionality systematically explores the joint and simultaneous influences of, for example, age, race and gender [41]. There are emerging attempts by some researchers to explore some of these inequalities within this review although this discussion remains underdeveloped. Kabell Nissen et al. [34] uses early warning scores and frailty tools to assess and categorize frail adjusted prognosis in ED and although they discuss the wider communication context as Bauer et al. [14] comments “Intersectionality’s questioning of the boundaries and sociohistorical construction of categories suggests that questioning, or at least acknowledging the limits of categorization is fundamental”. Validated tools can draw out principles of intersectionality or they can silence the macro power structures and intersections that can hinder and contribute to poorer outcomes and health inequality.

Discussion

The purpose of this review was to identify current considerations of intersectionality within ED palliative care for older adults. Use of three guiding frameworks provided a helpful basis for consideration of this complex but emerging perspective via an established methodology for integrative reviews [31], an appraisal model that also addresses non-research evidence and supports the integrative review process specifically [32], and a theoretical intersectional framing that encouraged a wider analysis of indirect intersectional considerations [15, 33].

We identified only a limited number of articles that had moved beyond standard demographic factors and made indirect reference to intersectional framing, though none overtly addressed the concept of intersectionality as it relates to this population. Based on this available evidence, we concluded that the current status of intersectionality in palliative care for older adults in the ED pertains to (1) intersectional elements or reference to such elements, embedded within the studies; and (2) the challenges of adapting quantitative methodologies to incorporate variables and approaches that would allow for intersectional analysis.

Five of the six articles included in the review were quantitative in nature, and as stated, none contained overt and intentional application of intersectionality, a factor not uncommon within quantitative research. This is in and of itself an important finding; the ED represents a gateway to healthcare for many people, and particularly for those with palliative care needs, the ED may be the only gateway available when palliative emergencies occur [8]. A systematic review examining intersectionality within quantitative studies found the utilization of the components related to an intersectional framework was poor with a lack of any definition (26.9% of papers), inadequate citation of foundational authors (32.0%) or of any intersectionality methods papers (47.0%) [14]. There was also limited acknowledgment of the interplay of social power within the analysis or discussion (17.5%). Harari & Lee [17] also found within their sample that nearly one-third (32%) of the reviewed publications specified no explanatory mechanisms whatsoever in their investigation of health disparities among intersectional groups. One of the challenges of examining intersectionality within any quantitative approach is the anti-categorical nature of intersectionality [42]. Categories are socially constructed and if the multidimensional nature of the individual is not adequately acknowledged, systematic inequalities can be amplified. For example, age multidimensionally may include, how families have divided and compensated domestic labor and the type of occupation and patterns of work of the older person in terms of retirement income in minority world countries or how stigma and ageism can affect social identity. These factors are often unacknowledged. Most quantitative approaches examine inter-categorical populations but Harari and Lee [17] comment “between group comparisons, on their own, only provide a limited picture of health disparities when within-group heterogeneity becomes obscured”. Furthermore, the use of within-group analyses can significantly advance the science and knowledge necessary for identifying the needs and developing interventions in palliative care and ED that are tailored for underrepresented older adults [43, 44].

Intersectionality provides a lens to explore the wider macro structures leading to inequality and complements work examining life course perspectives [45]. For example, certain racial/ethnic groups have premature onset of disease and mortality compared with others, resulting in presentation in middle rather than older age. Therefore, exploring categories related to older age may underestimate health disparities. As Forrester et al. [45] comment, “Precise methodological approaches are necessary to capture the aspects of healthy aging and to understand why healthy aging appears unattainable for some while present for others.” This becomes the challenge, for example, the instrumental papers within this review highlight how earlier papers that validate different tools/measures are often the foundation to form and validate further assessments with ED. This has the potential to limit methodological diversity since these validated measures become the gold standard for routine data collection and clinical decision-making. This can also lead to standardized inclusion criteria and categorization that can silence and exclude marginalized communities and underestimate health inequalities in older populations.

A final consideration in regards to the ED setting itself, which traditionally triages based on a main presenting factor. The design and structure of the ED has not historically lent itself to nuanced assessment processes that consider the intersectional factors contributing to cause of visits which may be beyond the presenting complaint. For example, a patient who presents to the ED due to a fall which resulted in fractures and suspected stroke will have the presenting concerns rapidly treated, but the cause may be overlooked, for example, reduced capacity of both the patient and their caregiver. Without a more nuanced assessment approach, needed referrals to social support or other resources may not be made. Though some might argue that this is a deeper level of assessment that should take place later, once the initial complaint has been stabilized, this argument fails to recognize that for some dyads, the underpinning, intersectional and palliative concerns are as important as the presenting need and should be addressed or acknowledged in some format in the ED [46].

The wide variety of topics addressed in the reviewed articles demonstrates the diverse set of care needs older adults with palliative care needs may present with to the ED. However, lack of assessment of the impact of intersecting variables is also common in research practice. For example, many studies list specified demographics of the populations included, but rarely provide a rationale for why those variables were selected, why others were excluded, or more importantly, what consideration was given to the influence that the intersection of these different variables may have had on outcomes.

Notably however, in some instances clinical practice has moved beyond the literature in regards to intersectional practices in ED palliative care for older adults. For example, some electronic health records now collect intersectional data, and in some instances, intersectionality is being assessed and considered in care pathways but without directly describing such assessments as intersectional. Recognition of this was reflected in this review, for example where study tools prevented a nuanced perspective, it was noted that inclusion of subjective identities and perspectives would have enriched the work and given a greater breadth of understanding, for example fear, knowledge, stigma, and preferences for decision-making [34, 36]. This also highlights that the ways people respond to the intersections they exist within and the subsequent inequities they may face may not be well captured in quantitative methodologies, particularly when considering inequities in both aging and palliative care [14, 19].

Strengths and Limitations

To the best of our knowledge, this is the first review of intersectionality for older adults with palliative care needs in the ED. The review highlights areas for further investigation, along with recommendations for modifications for current methodological approaches and data captures in research that would enable more nuanced investigation and analysis. However, it is possible that due to our search strategy, we did not capture all information on this topic, for example, exclusion of articles written in a language other than English, or due to different uses of terminology to represent intersectionality that we were unaware of. Further, the perspectives of the majority of the authors are framed from a western approach in which ageism represents a systemic inequity that is not the case in all cultures. Thus, there may be valuable insights demonstrating more inclusive, nuanced and holistic practices in other cultures that we did not capture. Despite this, the work in this review offers a unique, nuanced perspective on the work included that is intended to serve as a building point for future research to understand and improve the care of older adults with palliative care needs in the ED.

Conclusion

This integrative review examined the literature for inclusion of intersectionality and its implications in the provision of ED palliative care. Though we found no articles directly addressing intersectionality, six articles were identified and appraised that included indirect examination of concepts and components of intersectionality. Two areas of interest point to both strengths and opportunities in the literature; (1) intersectional elements, or reference to them, that were incorporated into the studies, and (2) challenges to the incorporation of the components of intersectionality into quantitative methodological approaches that would allow for intersectional analysis. The review, examining both the methodological approaches themselves, as well as study outcomes, identified future directions for this area. Namely, expanding ED triage assessment to include dimensions of intersectionality may help to reduce the inequities that are associated with triage based on a single presenting criteria; and that quantitative methodologies themselves may not adequately capture the nuances of intersectional dimensions and thus subjective perspectives may be especially important when considering inequities in aging and in palliative care in the ED. Carefully considering the implications for emerging studies in this area are important and urgent as intersectionality is a key component to the reduction of inequities of health and palliative care delivery in the ED.

Data Availability

Not applicable.