transferring them to a ward as death is
imminent. 32
Having dedicated space would also encourage
staff to reorient their thinking from the ED being
the ‘wrong place’ to die. Ensuring privacy and
explaining what to expect as death approaches is
important in allaying anxiety for family and
carers. Clinicians should never underestimate the
power of a kind word or gestures of empathy and
the enormous difference these can make to the
grieving process.
Care needs to be holistic. Common symptoms
requiring treatment in the older patient include
pain, difficulty in breathing, noisy respiratory
secretions, nausea and vomiting, dysphagia,
incontinence and anxiety. 29,30
Dyspnoea is experienced by many older
patients with end-stage cardiac and respiratory
conditions. This, and intractable pain, is often the
crisis point for patients and families who feel
unable to cope with the increasing severity of
symptoms and need the reassurance and support
of the ED. Although dyspnoea is a physical sign, it
can also be a manifestation of emotional distress.
Morphine, recommended by the World Health
Organization, is the most frequently used drug for
the symptomatic management of dyspnoea and is
included in their evidence-based list of essential
medicines in palliative care, which was updated
in 2013. Morphine has the advantage of also
relieving pain and anxiety but it is also important
to consider other likely causes of such distress.
Nursing interventions such as regular
repositioning as well as personal hygiene and
mouth care are fundamental for patient comfort.
Interventions such as intravenous cannulas or
urinary catheters must be justified for patient
comfort and clearly explained to the patient, their
family and carers. Clinicians should not overlook
the spiritual component of death and dying. In
References
1 Council of Europe. Committee
on Bioethics (DH-BIO) Guide on
the decision-making process
regarding medical treatment in
end of life situations 2014. www.
coe.int/en/web/bioethics/end-
of-life (accessed August 2019)
2 Cooper E et al. Palliative care
in the emergency department: A
systematic literature qualitative
review and thematic synthesis.
Palliat Med 2018;32(9):1443–54.
3 Gawande A. Being Mortal and
What Matters in the End. 2014.
4 Stephens C et al. Provider
perspectives on the influence of
family on nursing home resident
transfers to the Emergency
Department: Crisis at the end
of life. Curr Gerontol Geriatr Res
2015;2015;2015:893062.
5 Bailey C. Murphy R, Porock
D. Dying cases in emergency
places: Caring for the dying in
emergency departments. Soc Sci
Med 2011;73:1371–7.
6 Giscondi MA. A case for
education in palliative and
end of life care in Emergency
Medicine. Acad Emerg Med
2009;16(2):181–3.
7 Jelinek GA et al. Better
pathways of care: suggested
improvements to the emergency
department management of
people with advanced cancer J
Palliat Care 2014;30(2):83–9.
8 Shearer M, Ross-Adjie L, Rogers
JR. Understanding emergency
department staff needs and
perceptions in the provision of
palliative care. Emerg Med Aust
2014;26:249–55.
9 Fassier T et al. Who am I to
decide whether this person
is to die today? Physicians’
life-or-death decisions for
elderly critically ill patients at
the Emergency Department–ICU
interface: A qualitative study.
Ann Emerg Med 2016;68(1):
28–39.
10 Marck CH et al. Care of
the dying cancer patient in
the emergency department:
findings from a National survey
of Australian emergency
department clinicians. Int Med J
2014;44(4):362–8.
11 Wolf L et al. Exploring
the management of death:
Emergency nurses perceptions
of challenges and facilitators in
the provision of end of life care
in the emergency department. J
Emerg Nurs 2015;41:e23–e33.
12 Bailey C, Murphy R, Porock D.
Professional tears: developing
emotional intelligence around
death and dying in emergency
work. J Clin Nurs 2011;(23-
24):3364–72.
13 Kaiser Family Foundation.
Views and Experiences with End-
of-Life Medical Care in Japan,
Italy, the United States, and
Brazil: A Cross-Country Survey.
The Economist; April 2016.
14 Gomes B et al. Preferences
for place of death if faced with
advanced cancer: a population
Delivering good
EoLC for the
older patient
in the ED is
an increasing
imperative as
it is inevitable
that more older
people will spend
their last hours
in the ED
survey in England, Flanders,
Germany, Italy, the Netherlands,
Portugal and Spain. Ann Oncol
2012;23:2006–15.
15 Universal Declaration
of Human Rights 1948.
www.un.org/en/universwl-
declaration-human-rights
(accessed August 2019).
16 Kant I. In: Groundwork for
the Metaphysics of Morals
(translated by Wood A) New
Haven, Yale University Press.
2002:2–58.
17 Haugen HM. Inclusive and
relevant language; the use of
concepts of autonomy, dignity
and vulnerability in different
contexts. Med Health Care
Philosophy 2010:13(3)203–13.
18 Adler E, Qui Q. Performing sit
down medicine in a stand-up
place: is it time for palliative care
in the emergency department?
Emerg Med J. 2018;35(12):
730–1.
19 Royal College of Emergency
Medicine. End of life care
for adults in the emergency
department. www.rcem.
ac.uk/docs/College%20
Guidelines/5u.%20End%20
of%20Life%20Care%20for%20
Adults%20in%20the%20ED%20
(March%202015).pdf (accessed
August 2019).
20 European Society for
Emergency Medicine. European
recommendations for end of life
care for adults in departments
of emergency medicine.
8
HHE 2019 | hospitalhealthcare.com
our increasingly diverse society, death and dying
are understood and experienced differently
depending on cultural and religious meanings.
It is important to be culturally sensitive to diverse
rituals, fulfilling the wishes of the patient and
family as far as possible and reasonable should be
the goal.
Where there are language barriers, best
practice advocates the use of interpreters, but
older patients might be unable to relate to an
interpreter and prefer to have their families
interpret for them. Families may also find the
presence of an interpreter intrusive and quite
inappropriate in the private space of their dying
loved one. Staff should offer to call the Chaplin/
Priest/Imam/Rabbi or relevant spiritual leader at
any time if the patient desires.
Conclusions
Delivering good EoLC for the older patient in the
ED is an increasing imperative as it is inevitable
that more older people will spend their last hours
in the ED. An acceptance of EoLC is an important
function of the ED. Developing palliative and EoLC
skills is essential to ensure that patients die with
dignity and that the memory for families and
carers is not marred by experiences of poor care.
Having a designated space that provides
privacy and dignity is fundamental but this also
requires adequate staff who are trained in EoLC to
support the patient and family. Multidisciplinary
training and closer working with in-hospital and
community palliative care teams should be
encouraged. A goals-of-care approach will reassure
patients and their families that they are being
cared for. Small changes can make a big difference,
and with a different ethos and adequate resources,
we can ensure that the ED is not ‘the wrong place
to die’ and that older patients do not suffer
unnecessarily in their last hours.
https://eusem.org/wp-content/
uploads/2017/10/EuSEM-
Recommendations-End-of-life-
care-in-EDs-September2017.pdf
(accessed August 2019).
21 American College of
Emergency Physicians. Palliative
Medicine in the Emergency
Department. www.acep.
org/how-we-serve/sections/
palliative-medicine/palliative-
medicine-in-the-emergency-
department/ (accessed August
2019).
22 Leadership Alliance for the
Care of Dying People. One
Chance to Get It Right. https://
assets.publishing.service.gov.uk/
government/uploads/system/
uploads/attachment_data/
file/323188/One_chance_to_
get_it_right.pdf (accessed
August 2019).
23 Leadership Alliance for
the Care of Dying People.
Priorities of care for the dying
person. www.nhsemployers.
org/news/2014/06/leadership-
alliance- (accessed August 2019)
24 Taylor P, Dowding D, Johnson
M. Clinical decision making
in the recognition of dying:
qualitative interview study. BMC
Palliative Care 2017. https://
bmcpalliatcare.biomedcentral.
com/articles/10.1186/s12904-
016-0179-3 (accessed January
2019)
25 Whitehouse S. We need to
talk about death. Complaints
about end of life care 2013.
www.medicalprotection.org/uk/
casebook.
26 Arendt G et al. Preferences
for the emergency department
or alternatives for older people
in aged care: A discrete choice
experiment. Age Ageing
2017;46(1):124–9.
27 Fritz Z, Fuld J. Ethical issues
surrounding do not attempt
resuscitation orders: decisions,
discussions, and deleterious
effects. J Med Ethics 2010;
36(10):593–7.
28 Chen JL et al. Impact
of Do Not Resuscitation
Orders on quality of care
performance measures in
patients hospitalized with
acute heart failure. Am Heart J
2008;156:78–84.
29 Arabi YM, Al Sayyari A,
Moamary MS. Shifting paradigm:
from “No Code” and “Do-Not-
Resuscitate” to Goals of Care
Policies. Ann Thoracic Med
2018;2(25):67–71.
30 Fritz Z, Fuld JP. Development
of the Universal Form of
Treatment Options (UFTO)
as an alternative to Do Not
Resuscitation (DNACPR) orders:
a cross-disciplinary approach. J
Eval Clin Pract 2013;2:109–17.
31 Sokol DK. Cautionary tales
about DNACPR. BMJ 2016;352.
32 Beckstrand RL et al.
Emergency nurses suggestions
for improving end of life
care obstacles. J Emerg Nurs
2012;38(5):e7–e14.