Death in the Emergency Department
Experiences of death of patients.
Death is a common place thing in the emergency department, regardless of how many and varied the causes may be. However, we are not a facility that is designed to provide palliative care. We are by nature designed with the salvage of life and limb before anything else in mind. This is despite the multitude of deaths that occur in the emergency department [Chan 2004, Holbery & Newcombe 2016]. My exposure to palliative care is limited due to where I work. Broadly speaking, my experiences of death can be split into two categories:
- The catastrophic and rapid type of death. This can be illustrated with the examples of a cardiac arrest or trauma call in which, despite the best efforts of those involved, the patient dies very rapidly.
- The if not in the next five minutes but when? This is the patient who is brought into the emergency department and clearly moribund. They will die during this hospital admission at some stage. Most likely very soon after arrival.
More often the trajectory of death in the emergency department is a very steep one. Although the trajectories of deaths in the emergency department are often steep, we cannot ever say that there is nothing more that we could do. Providing physical comfort as opposed to fighting a hopeless cause and causing the inherent distress is something that we should be doing [Gisondi 2009].
Palliative Care Skills?
Ultimately, being better skilled in palliative care would be beneficial to the emergency department. Those of us who work in emergency care settings are by default geared to the rapid saving of life and limb. This has lead to us becoming rather heroic in our efforts to save life. Perhaps we ought not to be quite so. We now see death as a failing of our care rather than the natural event that it is, regardless of how unnatural the cause or causes may be. We cannot save everyone. Being better skilled in palliative care would mean that the moribund patient arriving at the emergency department would be recognised earlier and appropriate ceilings of care discussed thus preventing the associated heroism and inherent suffering caused by the procedures attached to it [Edwards & Griffiths 2011, Holbery & Newcombe 2016, Grudzen et al 2012].
What are the barriers to palliative care?
So what are the barriers to the provision of effective palliative care in the emergency department?
- Lack of skills and confidence
- No prior knowledge of patient’s wishes or family at times
- Heroism on the part of emergency department clinicians
Quest et al 2011, Grudzen et al 2012 and Ferero et al 2012
Time: in the UK we are obliged to work within a four hour window, that is all patients are admitted, treated, discharged or referred on to specialist services within four hours of arrival at the emergency department. This is an insufficient period of for us to determine what the wishes of the patients may be in regards to end of life care. Nor is it enough time to discuss with their relations if this is at all possible.
Heroism: as previously stated, we are an organisation established to save life and limb above all else. Perhaps this means that we now have an entrenched view that death is a failing on our part rather than the inevitable and natural event that it is. I don’t feel that we are overly heroic however we are highly skilled in delaying that event, if only for a few hours to allow a patient to be transferred out of the emergency department. Perhaps we try to salve our consciences with the knowledge that the patient left the department alive so our job is done.
Skills and confidence: we are not accustomed to the provision of palliative care in emergency departments. We have not the skill or knowledge as we rely on other services to do this for us. This is in part due to the majority of our deaths being so sudden and rapid there is seemingly little call to have skills in palliative care.
Resources: Dependent on size, your emergency department will be capable of handling many of the catastrophes that can befall the average person. However, we lack things like syringe drivers for administering end of life medication, we lack some of the medications and the skill to use these devices.
Final Thoughts (pun intended!)
In conclusion, there are several significant barriers to providing or more starting to provide palliative care in the emergency department. Most notable are the time and skills based constraints. We do not have the luxury of time that other areas are more blessed with (I am well aware of breaches and how long these can be) which allows the discussion of wishes and to do it properly. We are not skilled in the provision of palliative care so we lack the knowledge base to do it. We cannot be providing a skill without an astute knowledge base. I do feel that we can improve the provision of palliative care in the emergency department. There is a clear need for us to develop it given that there is a not insignificant population who would benefit from aggressive palliative care that begins in the emergency department as they are clearly moribund. Although there are good grounds for bringing about improvements in this there are obstacles to doing this and I feel that I’ve outlined them. We have to remember that death is inevitable, after all, who gets out alive anyway?
Despite Emergency medicine and nursing needing to improve on the recognition of the dying patient, this does need to be supported by other specialities and decisions need to be made earlier. That said, the public perception of death and dying is in great need of being altered. People need to understand better that life draws to a close. Sadly that close can be a premature and tragic one or the closing of a particularly long and fruitful innings but it must end none the less. The expectation that everyone can be saved and that emergency medicine can perform almost miraculous feats of resurrection needs to be banished. The public has to understand and be more aware and accepting of death. It needs to be discussed and no longer be the taboo that it would appear, at least to me, to be. We are reasonably good judges of when we can salvage someone, if there is the chance we will give it a damn good effort but if we cannot then we must be equally aggressive in our efforts at palliation and providing a dignified death.
Grudzen CR, Richardson LD, Hopper SS, Ortiz JM, Whang C, Morrison RS (2012) Does palliative care have a future in the emergency department? Discussions with attending emergency physicians. Journal of Pain and Symptom Management. 43, 1, 1-9
Forero R, McDonnell G, Gallego B, McCarthy S, Moshin M, Shanley C, Formby F, Hillman K (2012) A literature review on care at the end of life in the emergency department. Emergency Medicine International
Tom is a registered nurse working in emergency care settings splitting his time between ED and EAU. His passions involve furthering nurse education in regards to physical assessment combined with the assessment and care of the rapidly deteriorating patient.
He also has a keen interest in simulation learning. Tom has an interest in massive transfusion in trauma, having written his undergraduate dissertation on the subject.
Stereotypically lacking in attention span, usually well natured when adequately caffeinated.
Tom studied and now works in Oxfordshire