Exploring the quality of the dying and death experience in the Emergency Department: An integrative literature review

The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand

BACKGROUND

Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people.

OBJECTIVES

To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere.

METHODS

We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression.

RESULTS

From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation.

CONCLUSIONS

Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.

Overcoming the barriers to optimal end of life care in the emergency department

The focus of care in the emergency department (ED) is on saving or sustaining life, but some patients admitted to the ED die in the ED. Nurses whose focus is on saving lives may therefore find themselves providing end of life care to patients and their families in a stressful and distressing environment. Providing optimal end of life care involves reflecting on what a good death looks like and how patients can be supported to have a good death. This article describes the barriers to optimal end of life care in the ED and prompts nurses to think about how they can enhance their practice when caring for dying patients and their families.

Perspectives towards End-of-Life Care in the Emergency Department of Tertiary Public Hospitals—A Qualitative Analysis

Background and Objectives: End-of-life care in the emergency department (ED) is gaining importance along with the growth in the ageing population and those with chronic and terminal diseases. To explore key stakeholders’ perspectives and experiences regarding end-of-life care in the ED. Materials and Methods: A descriptive qualitative study was conducted from November 2019 to January 2020. Study participants were recruited from the EDs of three tertiary hospitals and community care settings in Singapore through purposive sampling. Data collection included focus group discussions with 36 ED staff, 16 community healthcare professionals, and one-on-one semi-structured interviews with seven family members. Results: Three main themes and several subthemes emerged from the data analysis. (1) Reasons for ED visits were attributed to patients’ preferences, families’ decisions, limited services and capabilities in the community, and ease of access. (2) Barriers to providing end-of-life management in the ED included: conflicting priorities of staff, cramped environment, low confidence, ineffective communication, and lack of standardised workflows. (3) Discussion about continuity of end-of-life care beyond the ED uncovered issues related to delayed transfer to inpatient wards, challenging coordination of terminal discharge from the ED, and limited resources for end-of-life care in the community. Conclusions: Key stakeholders reported challenges and shared expectations in the provision of end-of-life care in the ED, which could be optimised by multidisciplinary collaborations addressing environmental factors and workflows in the ED. Equipping ED physicians and nurses with the necessary knowledge and skills is important to increase competency and confidence in managing patients attending the ED at the end of their lives.

Patients' experiences and perceptions of dignity in end-of-life care in emergency departments: A qualitative study

AIMS

To explore and understand the experiences of patients with advanced illness in relation to dignity during end-of-life care in emergency departments.

DESIGN

Qualitative study based on Gadamer's hermeneutics.

METHODS

Between September 2019 and February 2020, 16 in-depth interviews were carried out with advanced illness patients who attended emergency departments. The participants were informed priorly and signed informed consent. The data were analysed using an inductive strategy for finding emerging themes. The Consolidated Criteria for Reporting Qualitative Research was used for writing the study's report.

RESULTS

In the data analysis process, two main themes emerged that glean the experiences of patients in relation to dignity during end-of-life care in emergency departments. 'Dignity as an individual's attribute' and 'Acting with dignity: Dignity as a behavioural attribute'.

CONCLUSION

Patient dignity in end-of-life care is centred around the principle of control (of oneself, one's death and one's emotions). The strategies required for patients to preserve their dignity can be somewhat incompatible with the dynamics and objectives of healthcare professionals who work in emergency departments.

IMPACT STATEMENT

The dignity of patients with advanced illness who attend emergency departments is a relevant issue that merits being addressed from the patients' perspective. Participants have identified that dignity is a way of being and behaving in the face of illness. Emergency departments need to respect end-of-life patients' desires by supporting and accompanying them, avoiding therapeutic obstinacy. We recommend care to be centred on patients' well-being, to respect their autonomy and decision-making processes, and to allow prompt referrals to palliative care services.

PATIENT OR PUBLIC CONTRIBUTION

Managers from the Emergency Departments participated in the study design and patients' recruitment. Patients' relatives were informed about the study's aim, and they contributed to the development of the interview protocol.

Death and End-of-Life Care in Emergency Departments in the US

IMPORTANCE

There are more than 140 million annual visits to emergency departments (EDs) in the US. The role of EDs in providing care at or near the end of life is not well characterized.

OBJECTIVE

To determine the frequency of death in the ED or within 1 month of an ED visit in an all-age, all-payer national database.

DESIGN, SETTING, AND PARTICIPANTS

The retrospective cohort study used patient-level data from the nationally representative Optum clinical electronic health record data set for 2010 to 2020. Data were analyzed from January to March 2022.

EXPOSURES

Age, Charlson Comorbidity Index (CCI), and year of ED encounter.

MAIN OUTCOMES AND MEASURES

The primary outcome was death in the ED, overall and stratified by age, CCI, or year. A key secondary outcome was death within 1 month of an ED encounter. We extrapolated to make national estimates using US Census and Nationwide Emergency Department Sample data.

RESULTS

Among a total of 104 113 518 individual patients with 96 239 939 ED encounters, 205 372 ED deaths were identified in Optum, for whom median (IQR) age was 72 (53 to >80) years, 114 582 (55.8%) were male, and 152 672 (74.3%) were White. ED death affected 0.20% of overall patients and accounted for 0.21% of ED encounters. An additional 603 273 patients died within 1 month of an ED encounter. Extrapolated nationally, ED deaths accounted for 11.3% of total deaths from 2010 to 2019, and 33.2% of all decedents nationally visited the ED within 1 month of their death. The proportion of total national deaths occurring in the ED decreased by 0.27% annually (P for trend = .003) but the proportion who died within 1 month of an ED visit increased by 1.2% annually (P for trend < .001). Compared with all ED encounters, patients with visits resulting in death were older, more likely to be White, male, and not Hispanic, and had higher CCI. Among ED encounters for patients aged older than 80 years, nearly 1 in 12 died within 1 month.

CONCLUSIONS AND RELEVANCE

This retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently.

Mapping the future for research in emergency medicine palliative care: A research roadmap

BACKGROUND

The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation.

OBJECTIVE

The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research.

METHODS

Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics.

RESULTS

Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC.

CONCLUSIONS

There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

Emergent care nurses' perceived self-competence in palliative care and its predictors: A cross-sectional study

AIM

To describe the prevalence of perceived self-competence in palliative care among emergent care nurses, and explore its predictors.

BACKGROUND

Emergent care nurses have a responsibility to develop palliative care competence to enhance the quality of life of dying patients and their families in the emergency department.

METHODS

With a convenience sample, a cross-sectional study was conducted among 415 emergent care nurses from 22 hospitals in China. Descriptive analysis, Spearman correlation analysis, and multivariate linear stepwise regression were performed.

RESULTS

Variables including marital status (single), emergency department not implementing palliative care, no palliative care training, and true cooperation dimension were selected as independent predictors and explained 19.9% of variation in the regression model.

CONCLUSIONS

Interventions to improve healthy work environments, offering palliative care training, advocating for policies in palliative care, and offering support to unmarried nurses can advance nurses' palliative care competence.

IMPLICATIONS FOR NURSING MANAGEMENT

This is the first study of emergent care nurses in China aimed at identifying predictors associated with palliative care self-competence. It is significant in that palliative care training and a cooperative work environment are required to encourage the development of palliative care.

Which factors influence the quality of end-of-life care in interstitial lung disease? A systematic review with narrative synthesis

BACKGROUND

People dying from interstitial lung disease experience considerable symptoms and commonly die in an acute healthcare environment. However, there is limited understanding about the quality of their end-of-life care.

AIM

To synthesise evidence about end-of-life care in interstitial lung disease and identify factors that influence quality of care.

DESIGN

Systematic literature review and narrative synthesis. The review protocol was prospectively registered with PROSPERO (CRD42020203197).

DATA SOURCES

Five electronic healthcare databases were searched (Medline, Embase, PubMed, Scopus and Web of Science) from January 1996 to February 2021. Studies were included if they focussed on the end-of-life care or death of patients with interstitial lung disease. Quality was assessed using the Critical Appraisal Skills Programme checklist for the relevant study design.

RESULTS

A total of 4088 articles were identified by initial searches. Twenty-four met the inclusion criteria, providing evidence from 300,736 individuals across eight countries. Most patients with interstitial lung disease died in hospital, with some subjected to a high burden of investigations or life-prolonging treatments. Low levels of involvement with palliative care services and advance care planning contributed to the trend of patients dying in acute environments. This review identified a paucity of research that addressed symptom management in the last few days or weeks of life.

CONCLUSIONS

There is inadequate knowledge regarding the most appropriate location for end-of-life care for people with interstitial lung disease. Early palliative care involvement can improve accordance with end-of-life care wishes. Future research should consider symptom management at the end-of-life and association with location of death.

The perspective of professional caregivers working in generalist palliative care on 'good dying': An integrative review

In today's industrial societies, many people die receiving professional care. Although specialist palliative and hospice care have often been identified as ideal care approaches to promote good dying, more people die receiving generalist palliative care. This integrative review examines how professional caregivers providing generalist palliative care in hospitals, nursing or private homes define good dying. Furthermore, through comparative analysis of existing empirical studies, it explores conceptual aspects in researching good dying that better reflect the social complexity of this phenomenon. Three databases (Scopus, MEDLINE, and CINAHL) were searched for peer-reviewed studies published between January 2000 and April 2020. Studies were selected if they presented original empirical findings from qualitative or quantitative studies on the perspective of professional caregivers in generalist palliative care (nurses, physicians, surgeons, clergy, and other staff) on good dying or related concepts (e.g., good death, dignity in dying, or quality of life at the end of life). 42 studies were included in the review. They identified good dying as expected, accepted and prepared dying, as free from pain and suffering, as socially embedded, as being at peace with one's life and situation, as supported with individualised and holistic care, as based upon professional cooperation and communication, and as in a peaceful and private environment. The paper concludes that the perspective of professional caregivers in generalist palliative care shares many elements of good dying with societal and specialist palliative care discourses around good dying. Through comparing the different studies, the review found that studies that explicated who benefitted from ideals and practices of good dying, questioned the dichotomous categorisation of good/bad dying, or discussed the compatibility of elements of good dying, provided more nuanced perspectives on this topic. Thus, the review calls for a more systematic analysis of these aspects in research of good dying.

Differences in end-of-life care and outcomes in palliative consultation-eligible patients with and without do-not-resuscitate orders: A propensity score-matched study

BACKGROUND

The primary objective of palliative care, not synonymous with end-of-life (EOL) care, is to align care plans with patient goals, regardless of whether these goals include the pursuit of invasive, life-sustaining procedures, or not. This study determines the differences in EOL care, resource utilization, and outcome in palliative care consultation-eligible emergency department patients with and without do-not-resuscitate (DNR) orders.

METHODS

This is a retrospective observational study. We consecutively enrolled all the acutely and critically ill emergency department patients eligible for palliative care consultation at the Taipei Veterans General Hospital, a 3000-bed tertiary hospital, from February 1 to July 31, 2018. The outcome measures included in-hospital mortality and EOL care of patients with and without DNR.

RESULTS

A total of 396 patients were included: 159 with and 237 without DNR. Propensity score matching revealed that patients with DNR had significantly shorter duration of hospital stay (404.4 ± 344.4 hours vs 505.2 ± 498.1 hours; p = 0.037), higher in-hospital mortality (54.1% vs 34.6%; p < 0.001), and lower total hospital expenditure (191 239 ± 177 962 NTD vs 249 194 ± 305 629 NTD; p = 0.04). Among patients with DNR, there were fewer deaths in the intensive care unit (30.2% vs 37.0%), more deaths in the hospice ward (16.3% vs 7.4%), more critical discharge to home (9.3% vs 7.4%), more endotracheal removals (3.1% vs 0%; p = 0.024), and more narcotics use (32.7% vs 22.1%; p = 0.018).

CONCLUSION

The palliative care consultation-eligible emergency department patients with DNR compared with those without DNR experienced worse outcomes, greater pain control, more endotracheal extubations, shorter duration of hospital stay, more critical discharge to home, more hospice referrals, and 23.3% reduction in total expenditure. There were fewer deaths in the ICU among them as well.

What is a compassionate response in the emergency department? Learner evaluation of an End-of-Life Essentials online education module

Objective

To evaluate the End‐of‐Life Essentials education module ‘Emergency Department End‐of‐Life Care’ and explore learners' views on what constitutes a compassionate response in the ED.

Methods

The present study used a multi‐methods approach. Learners comprised a mix of nurses, doctors and allied health professionals. A quantitative pre‐post evaluation analysis of learners' (n = 959) knowledge, skills, attitude and confidence was conducted, along with a qualitative thematic content analysis on learner responses (n = 538) to the post‐evaluation question, ‘What is a compassionate response for you in the emergency department?’ Data were extracted for a 12‐month period, 6 May 2019 to 6 May 2020.

Results

Learners' post‐evaluation ranks of knowledge, skill, attitude and confidence were significantly higher than the pre‐evaluation ranks (P < 0.001). Emerging themes from the qualitative data were organised into three overarching categories: communication skills (e.g. listening and use of names), care discussion and provision (e.g. provide information and discuss care plans) and humanising healthcare (e.g. emotional support and empathy, taking the time, and offering kindness and comfort).

Conclusion

The ‘Emergency Department End‐of‐Life Care’ module had a significant positive impact on learners in relation to perceived knowledge, skill, attitude and confidence. This evaluation suggests that the End‐of‐Life Essentials ED module could be a useful online learning resource for health professionals.

Exploring the components of the quality of death in Japanese emergency departments: A qualitative study

BACKGROUND

The need to care for patients who die in the emergency department is increasing in Japan, and emergency nurses are required to provide end-of-life care to ensure that patients experience a good death. However, the components of the quality of death and what constitutes a good death for patients dying in the emergency department are unclear.

AIM

This study aimed to explore the components of the quality of death for patients who die in emergency departments of Japanese hospitals.

METHODS

This study employed a qualitative design. An inductive content analysis was conducted based on semi-structured interviews with 26 participants, which included 15 emergency nurses, five emergency physicians, and six bereaved families.

RESULTS

Seven components of quality of death were identified: (1) transition to the end-of-life phase after receiving the best treatment, (2) dying without suffering, (3) having the patient's wishes respected, (4) having a loved one nearby, (5) maintaining human dignity, (6) having no change in appearance, and (7) not making the family feel guilty.

CONCLUSION

These components suggested that emergency nurses should: support patients' receipt of the best treatment and foster their smooth transition to the end-of-life phase at the appropriate time, ensure that the patients in the end-of-life phase spend time with their loved ones immediately before their death, enable the maintenance of human dignity and patient identity of end-of-life patients, and make sure that the families of end-of-life patients do not feel guilt.

Death and Dying in the Emergency Department

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse (APRN) and to assist with the translation of research into practice. For each column, a topic and a particular research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. Our current column discusses factors associated with the quality of the death and dying experience in the emergency department (ED) from the perspective of health care providers with implications for APRN practice and strategies using the following study: . "Exploring the quality of the dying and death experience in the emergency department: An integrative literature review," International Journal of Nursing Studies, 85, 106-117. Our case involves a man with metastatic colon cancer where his oncology nurse practitioner recommends no further treatment and tells him he has approximately 6 months to live.

Initiating palliative care consultation for acute critically ill patients in the emergency department intensive care unit

BACKGROUND

Little is known about the characteristics of patients needing palliative care consultation in the emergency department (ED). This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, health care resources, and end-of-life (EOL) care in the intensive care unit in ED (EICU).

METHODS

We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and health care utilization.

RESULTS

A total of 796 patients were screened, with 396 eligible and 400 noneligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% CI, 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in noneligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in noneligible patients (40.7% vs 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than noneligible patients (p < 0.05).

CONCLUSION

Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of health care resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family on palliative care consultations and hospice care are required.