enshrined in the 1948 Universal Declaration of
Human Rights. 15 Autonomy as a concept is derived
from the ancient Greeks. More recent concepts of
autonomy are philosophical products of the
Enlightenment and the thinking of philosophers
such as John Stuart Mill and Immanuel Kant, the
latter proposing the inviolability and intrinsic
nature of dignity. 16,17
Respecting patient dignity and autonomy means
listening and involving patients in decisions about
their care. This can take time and calls for what
one physician referred to as ‘doing sit down
medicine in a stand up place’. 18 Time is a precious
commodity that is often in short supply in EDs but
short-changing older patients and their relatives in
terms of time at the point of maximum
vulnerability in their lives is not an option.
This need for palliative and EoLC skills for ED
clinicians has been recognised by emergency
medicine colleges and associations globally and
guidelines exist to support ED clinicians, all of
which emphasise the importance of respect for
the dignity and autonomy of the person. 19–21
In the UK in 2013, the Leadership Alliance for the
Care of Dying People, published two documents:
One Chance to Get it Right and Priorities of Care for the
Dying Person, 22,23 which set out the approach to
caring for dying patients under five priorities.
These are:
• Recognising that someone is dying
• Communicating sensitively with the patient
and their family
• Involving them in decisions
• Supporting them and their family
• Creating an individual plan of care that includes
adequate pain relief, nutrition and hydration.
Recognising dying
Recognising dying is an essential clinical skill but
nonetheless challenging for most physicians,
especially in the ED where there might be no
previous knowledge of the patient or his/her
medical history. 24 Patients must be assessed by
a doctor competent to judge whether the
patient’s condition is treatable or whether death
is likely in the next few hours or days. 22,23
Physicians need to be mindful that initiating end
of life talks in the ED can be upsetting for
patients and families. Finding the right words
calls for patience and understanding; privacy for
the patient and family must be assured. Being
frank and honest with the family and carers is
important. These conversations can be very
emotional, thus using clear plain language,
avoiding euphemisms to minimise any
misunderstanding, is essential.
Poor communication at the outset can
intensify distress for the patient and carers, and
can be the source of difficulty for subsequent care
givers and sometimes the source of a complaint. 25
Older patients feel vulnerable and are fearful of
being alone in the ED, and staff need to be
mindful of this. 26 Ensuring patients and their
family/carers know the name of the doctor and
nurse caring for them helps minimise this abject
sense of loneliness. Listening actively is key to
establishing good rapport. Allow the patient time
to talk if he/she can. Remember, patients with
cognitive impairment may be slow to answer.
A good preamble is to ask the patient or carers
what they already know about their illness; this
Recognising
dying is seen
as an essential
clinical skill
but nonetheless
challenging for
most physicians,
especially in
the ED
7
HHE 2019 | hospitalhealthcare.com
gives the patient and/or carers ownership of the
conversation and can often be quite insightful.
Asking the patient about their fears, their goals
and what they would like to have done for them
will give the physician the way to broach the
issue of resuscitation if appropriate.
Responsinf to patient and carer emotions is
particularly pertinent in EoLC. As the emotional
burden of EoLC and the skills to respond has been
cited as a barrier by staff, this could be the right
time to involve the palliative care team for added
support and advice.
Do Not Attempt Resuscitation (DNAR) orders
have had their uses in recognising the limited
value of some medical interventions and
treatments for older patients with terminal
medical conditions, have always been fraught
with misunderstanding and ethical difficulties. 27
The European Convention on Human Rights
mandates that physicians involve patients in
making DNAR decisions. 28 Physicians should be
aware that such conversations can be received by
patients and carers with unease and suspicion of
DNAR as a withdrawal of treatment. This concern
has some veracity as there is evidence that
suggests in-hospital mortality is higher in patients
with DNAR orders than for those with similar
comorbidities and severity of illness without
a DNAR in place. 28,29 The physician needs to
reassure the patient and carers that DNAR only
applies to CPR, and not medication, comfort
measures or general care.
Nonetheless, concerns about a DNAR and the
associated difficulties have led to calls for a
change of approach from DNAR to goals of care or
universal forms of treatment. 29,30 Goals of care are
a multidisciplinary approach where the starting
point is about what can be done rather than what
cannot. It is quite a different approach, whereby
the aim is to decide treatment choices and care
needed. 29
Unlike DNAR, the goals of care model places
greater emphasis on emotional support for
patients and their families and is an altogether
more positive but realistic approach. 29 Patients
may be more receptive to this approach and
physicians may be more inclined to initiate such
conversations with patients on these terms. The
Universal Form of Treatment Options (UFTO) is a
similar concept which was developed with
patients, doctors and nurses as an alternative
approach to resuscitation decisions. In this
approach, resuscitation decisions are
contextualised within overall goals of care. 30
Where patients lack capacity to make decisions
about CPR or goals of care, the physician must ask
whether there is a Lasting Power of Attorney or
an Advance Directive relating to CPR in place. In
the absence of either, the physician needs to
consult those close to the patient, providing it is
appropriate to do so. Those consulted must be
advised that the overall decision lies with the
clinical team. 31
Supporting the older patient and family as
death is imminent is one of the many privileges
of our roles and the very cornerstone of caring
but it can be a challenge to achieve in a crowded
department. Having a dedicated room in the ED,
or at least redesigning the physical space of the
ED to accommodate EoLC with allocated nurse
staffing, is advisable and preferable to