EMERGENCY AND CRITICAL CARE
End of life care for the
older patient in the ED
Few would dispute the importance of end of life care for patients and
their families, but it is clear from the literature that in emergency departments,
it is not always as good as it needs to be
Mary Dawood
RN BSc(Hons) MSc
PGDip
Imperial College
Healthcare Trust,
London, UK
How people die
remains in the
memory of those
who live on
Dame Cecily Saunders
(1918–2005), founder of the
modern hospice movement
End of life care (EoLC) is defined as enabling and
supporting the palliative care needs of both
patient and family to be identified and met
throughout the last phase of life and into
bereavement. It includes management of pain and
other symptoms and provision of psychological,
social, spiritual and practical support. 1 Few would
dispute the importance of EoLC for patients and
their families, but it is clear from the literature
that EoLC for older patients in emergency
departments (ED) is not always as good as it
needs to be. 2
Indeed, Atul Gawande, the physician and
author, believes our reluctance to honestly
examine the experience of aging and dying has
increased the harm we inflict on people denying
them the basic comforts they most need. 3
This is a sad indictment but such is the
paradox of modern medicine that more people
are living longer, often with chronic disease
which, for many, results in frequent admissions
to the ED. Older patients are often referred to the
ED from nursing homes and their own homes
when staff or family feel unable to cope with
increasing severity of symptoms; this happens
even where advanced directives are in place. 4
With demand and need for inpatient beds far
outweighing supply in most parts of the world,
crowding in EDs is commonplace and sadly, but
inevitably, some patients (particularly older
patients) will end their days in the ED. It behoves
us as caring professionals to urgently rethink our
response to the needs of older patients dying in
the ED so we are not denying them comfort and
dignity in their last hours.
The wrong place to die?
There is a perception among ED professionals
that the ED is “the wrong place to die”; this
perception is understandable because the ED is
traditionally designed to save lives, the focus
being on saving lives rather than palliation. 5
Nonetheless in the current landscape this
thinking is outdated and serves as both an excuse
and an impediment to improving end of life care
in the ED. Some ED physicians have expressed
concerns over a lack of training and a lack of
skills in caring for patients at the end of life. 6–9
Others have described helping someone die in
conditions of comfort, dignity and respect as
being one of the most gratifying clinical
experiences, acknowledging that doing this in the
ED is not easy. 10 Research suggests that nurses
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HHE 2019 | hospitalhealthcare.com
overall are comfortable providing EoLC in the ED
but often grapple with inadequate staffing levels
and the competing pressures of the ED, alongside
delivering the care the older patient needs and
deserves and the emotional labour this
appropriates. 11,12 It would appear, however, that
this professional view of the ED as being ‘the
wrong place to die’ is not at altogether at odds
with public perception and aspiration. Research
globally has found that most people, when asked,
would prefer to die in their own home
surrounded by friends and families; however,
most, particularly in the developed world
anticipate they will die in hospital 13,14
Respecting dignity and autonomy
Delivering good EoLC in the ED is achievable and
irrespective of constraints older patients and their
families are deserving of privacy, dignity and
compassion at the most vulnerable point in their
lives and we have a duty to try our utmost to
achieve this.
Central to good EoLC is having respect for the
dignity and autonomy of the person; this ethos is