Practice Review
Emerg Med J: first published as 10.1136/emermed-2019-208632 on 13 August 2019. Downloaded from http://emj.bmj.com/ on 20 August 2019 at University of Warwick. Protected by
Correspondence to
Mary Dawood, Emergency
Department, Imperial College
NHS Trust, London W2 1NY, UK;
​mary.​dawood@​nhs.​net
Received 1 April 2019
Revised 24 July 2019
Accepted 24 July 2019
© Author(s) (or their
employer(s)) 2019. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: Dawood M.
Emerg Med J Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
emermed-2019-208632
End of life care in the emergency department
Mary Dawood
Abstract
The importance of end of life care (EoLC) for patients and
their families is well documented, however, the skills and
knowledge of emergency clinicians in delivering EoLC is
not widely understood but it is clear from the existing
literature that we fall short in delivering consistently
good EoLC although there is recognition of the need
to improve. This paper will acknowledge the challenges
of delivering good EoLC in the emergency department
(ED) but more importantly consider practical ways of
improving EoLC in the ED in line with best practice
guidelines on EoLC.
We have the opportunity to refashion our institu-
tions, our culture, and our conversations in ways
that transform the possibilities for the last chapters
of everyone’s lives.”
― Atul Gawande, Being Mortal: Medicine and
What Matters in the End.
Introduction
The importance of end of life care (EoLC) for
patients and their families is well documented. The
skills and knowledge of emergency clinicians in
delivering EoLC is not widely understood but it is
clear from the existing literature that we fall short
in delivering the consistently good EoLC. However,
there is recognition of the need to improve.1
Increasing attendances to the emergency depart-
ment (ED) of patients in the last days or hours of
life is inevitable as a result of longevity, medical
advances and more effective management of
a chronic disease. In some departments advances
in major trauma care have resulted in many more
patients particularly older patients surviving the
initial insult and being conveyed to the ED often
with catastrophic injuries where medical interven-
tions are futile and the initiation of palliation and
EoLC would be the kindest and most dignified
course of action. Similarly, patients from nursing
homes are often referred to the ED when staff or
family feel unable to cope with increasing severity
of symptoms, this can often be the case out of hours
when community palliative care teams are not so
easily accessible.2 Families often need added support
in the face of increased physical and mental distress
in their loved one even where advanced directives
are in place.3 In these situations, paramedic staff
often feels pressured to convey such patients to the
ED against their better judgement.4 With demand
for inpatient beds far outstripping supply in most
parts of the world resulting in crowding in EDs,
emergency clinicians need to adapt their skills to
meet this growing need.
The culture of emergency medicine to provide
stabilisation in acute emergencies is often at odds
Dawood M. Emerg Med J 2019;0:1–6. doi:10.1136/emermed-2019-208632
with the culture of palliative and EoLC, which
balances quality of life against the burdens of inva-
sive treatments.5 Much of the evidence to date is
unequivocal in highlighting the barriers to good
EoLC in the ED which include: professional atti-
tudes/understanding, a widespread perception
of the ED being the ‘wrong place to die’,6–8 the
emotional burden, lack of space, time, staffing
resources and the socio/family context.6–9 Some
ED physicians are keen to develop skills in pallia-
tive care but have expressed concerns over a lack
of training and a lack of skills in caring for patients
at the end of life.10–14 A qualitative study by Wolf
et al found that emergency nurses are comfortable
providing EoLC in the ED but cite the mismatch
between the goals of the ED and those of EoLC care
as difficult to reconcile.15 Another study found that
nurses find reward in the EoLC by investing them-
selves in the nurse–patient relationship, thereby
developing emotional intelligence which ultimately
creates a more positive experience for the patient
and their relatives.16
Most people when asked would not choose to
end their days in the ED but nonetheless many,
copyright.
especially in developed health systems, antici-
pate that they will die in hospital.17 18 Regardless
of perceptions and expectations, the reality is the
ED is the place where people most frequently seek
urgent care.19
The need for palliative and EoLC skills for ED
clinicians has been recognised by emergency medi-
cine colleges and associations globally and there
are clear guidelines to support ED clinicians.20–22
Furthermore, the American Board of Medical
Specialities established hospice and palliative
care as a sub-specialty of emergency medicine in
2006.22
In the UK in 2013, the Leadership Alliance for
the care of the dying, published two documents,
One Chance to Get It Right and Priorities of Care
for the dying person.23 24 which set out the approach
to caring for dying patients under five priorities as
follows:
►► Recognising that someone is dying.
►► Communicating sensitively with them 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.
These principles mirror the aforementioned
guidelines all of which emphasise the impor-
tance of respect for the dignity and autonomy of
the person.20–22 This paper will consider ways of
improving EoLC in the ED with respect to the
priorities listed above.
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 Practice Review

Emerg Med J: first published as 10.1136/emermed-2019-208632 on 13 August 2019. Downloaded from http://emj.bmj.com/ on 20 August 2019 at University of Warwick. Protected by
Delivering good EoLC
Recognising dying
Recognising dying is an essential clinical skill key to initi-
ating  EoLC, yet physicians, in general, are poor prognosti-
cators, even in palliative care where the patient may be well
known.25–27 The imminence of death is hard to predict but
certain signs have been traditionally recognised as heralding
death such as profound weakness, a patient being bed-bound or
comatose, only able to take sips of fluid, changes in breathing
pattern/breathlessness, skin changes, weak pulse and falling
blood pressure.28 However, the evidence base for these signs is
limited, and these signs are not exclusive to dying but could be
due to potentially reversible illness. Figure 1  PREPARED Model (adapted from Clayton et al30).
A Swedish study using multidisciplinary focus groups
explored the experiences of staff in identifying early and late
signs preceding dying in older patients. One early sign that the and prognosis. These include the PREPARED model,30 the
participants identified was resignation, for example, withdrawal Sage and Thyme model31 and the SPIKES model,32 all are used
from social contexts, lack of motivation and low mood. Late in palliative care for conveying upsetting news. The Sage and
signs that precede dying were identified as reduced circulation, Thyme model is mainly used by community nurses but the
increasing worry and anxiety, stopping eating and drinking, loss PREPARED model (figure 1) and the SPIKES model (figure 2)
of consciousness and marked changes in breathing patterns.29 It could be helpful to ED physicians in providing structure for
is important therefore that very ill and seriously injured patients difficult conversations.
brought to the ED or those whose condition deteriorates in the
ED be assessed by a doctor competent to judge whether the
patient’s condition is treatable or whether death is imminent
in the next few hours or days.23 24 Any decisions/interventions
need to be regularly reviewed and revised as the situation might
change.
Initiating end of life talks in the pressured environment that
is the ED can appear ill-timed and insensitive. Nonetheless, the

copyright.
clinician needs to be honest and open with the family and carers.
Where it is considered appropriate to initiate such conversations,
the timing of the conversation is of the essence and privacy for
the patient and family must be assured. Poor communication at
the outset is upsetting for relatives and carers, makes it difficult
for colleagues caring for the patient at a later stage and is some-
times the root cause of a complaint. Listening actively is key to
establishing patient rapport. Allow the to patient talk if he/she
can. It is important not to interrupt or break in with impres-
sions or questions. If there is a need to document, explain the
need but reassure the patient that he/she is not being ignored.
Such approaches convey clinician interest and attention. Using
clear plain language and avoiding euphemisms to minimise any
misunderstanding is essential. Most physicians know they never
get a second chance to deliver bad news better or differently,10
so finding the right words and initiating such conversations calls
for tact and empathy.
A good starting point is to ask the patient what they already
know about their diagnosis, this opening question will often
reveal more than one might expect making further probing
unnecessary. Asking the patient about their fears, their goals
and what they would like to have done for them will give the
clinician the way into broaching the issue of resuscitation. As
far as is possible and within reason, the dying person, and those
caring for them, should be involved in decisions about treatment
and care. The person and their family should know the name
of the doctor and nurse responsible for their care. Respect for
the dignity and autonomy of the individual must underpin all
actions.

Communication models
In recent years frameworks have been developed which focus on
informing the patient and carers about the patient’s condition Figure 2  Spikes Model (adapted from Baile et al32).
2 Dawood M. Emerg Med J 2019;0:1–6. doi:10.1136/emermed-2019-208632

Figure 3  NURSE mnemonic (adapted from Back et al50).
An important component of communication in end of life
situations is responding to patient and carer emotions. As
the emotional burden of EoLC and the skills to respond has
been cited as a barrier by staff who are also trying to manage
competing pressures in the ED, the NURSE mnemonic (figure 3)
may be helpful when responding to emotional and difficult
conversations.
Involving patients and carers in decisions
DNAR versus goals of care
Ceilings of treatment and do not attempt resuscitation (DNAR)
decisions have had their uses in recognising the limited value
of some medical interventions and treatments in patients with
terminal medical conditions but there has also been a misunder-
standing, inconsistencies and ethical difficulties in their appli-
cation.33 It is important to remember that failure to involve the
Figure 4  Comparison between the traditional model of no code or DNR and the goals of care models (adapted from Arabi et al).38 DNR, do not
resuscitate.
Dawood M. Emerg Med J 2019;0:1–6. doi:10.1136/emermed-2019-208632
Practice Review
Emerg Med J: first published as 10.1136/emermed-2019-208632 on 13 August 2019. Downloaded from http://emj.bmj.com/ on 20 August 2019 at University of Warwick. Protected by
Figure 5  Supporting the patient and family. CPR, cardiopulmonary
resuscitation; HDU, high dependency unit; NIV, Non invasive ventilation.
patient in DNAR decisions breaches article 8 of the European
Convention on Human Rights—namely, the right to respect for
private life which includes respect for the patient’s autonomy,
integrity, dignity and quality of life.34 It is not always feasible to
either make or be aware of existing DNAR decisions in the ED
as there is frequently not enough information on which to base
such a decision. Nonetheless having to make immediate DNAR
decisions is difficult for even the most experienced physician.
Relationships that can be built up in days or weeks in palli-
copyright.
ative settings need to be formed in hours or even minutes in
the ED.15 Listening to the patient and respecting his/her views
is important but it is also important to balance this against
the expert clinical judgement which may be different to what
the patient wants. Empathetic communication and reassurance
are essential as DNAR can be perceived by patients and carers
with alarm and suspicion as a withdrawal of treatment. This
concern is not without foundation as there is some 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.35 36 Also, some clinicians still
3
 Practice Review
interpret DNAR as a withdrawal of treatment37 and nurses have
commented that once a DNAR has been confirmed, there is a
sudden relinquishment of medical care.9
In the light of such concerns and of recent litigation, there
have been calls for a change of approach from DNAR to goals of
care or Universal Forms of Treatment33 (figures 4 and 5).
Goals of care are not the same as advanced care planning or
DNAR, it is a different breadth of concept where the under-
pinning aim is to decide treatment choices and care needed.38
Its starting point is positive of what can be done rather than
what cannot or should not. It is a multidisciplinary approach as
opposed to a single discipline focus where patient preferences/
values should inform medical advice and shared decision making.
Unlike DNAR, the goals of care model emphasises emotional
support for patients and their families.3 Patients may be more
receptive to this approach and doctors may be more willing to
initiate such conversations with patients on these terms
The Universal Form of Treatment Options (UFTO; figure 5) is
a similar concept which was developed iteratively with patients,
doctors and nurses as an alternative approach to resuscitation
decisions. This universal approach where resuscitation decisions
are contextualised within overall goals of care is a one-page
document where discussions and clinical conditions are docu-
mented first; then clarification of goals of overall treatment
(active treatment or optimal supportive care) are outlined; there
is also a free text box for ‘opting out’ of invasive treatments.
Supporting the patient and family in the ED setting can be
challenging in terms of time pressures, privacy and ensuring a
quieter place for the family and dying person to be together.
However, it is what patients expect of us and it is the last kind-
ness we can offer that might make a difference to the grieving
process. Explaining to the family and carers what to expect when
death is imminent, particularly changes in breathing patterns, is
important. This helps to allay the fear and anxiety that so often
contributes to a less than good experience for the family. Having
an EoLC room in the ED or at the very least redesigning the
physical space of the ED to accommodate EoLC with allocated
nurse staffing is advisable and preferable to rushing the patient
to a ward especially if death is imminent.6 Having a dedicated
room would also encourage a different mindset from the ED
being the ‘wrong place’ to die. This mindset ignores the reality
of what is occurring in most EDs and is a barrier to improving
the environment for EoLC. Many EDs now have a dedicated
room/cubicle for frail older patients or patients with dementia
and this could be sufficiently flexible to accommodate a dying
patient and their carers if no other private space is available. In
our current healthcare landscapes driven by targets and perfor-
mance indicators, there remains a need for minimum standards
to be set for an EoL room in all EDs, for the dying patient and
loved ones to be together in peace, dignity and comfort at the
most vulnerable point in life. It is recommended that the interior
design of palliative care accommodation and places for those at
the end of life should be of a more domestic aesthetic in deco-
ration than a clinical one.39 40 Having such a facility in the ED
would not only ensure patient privacy and comfort and minimise
noise intrusion but may also reduce the emotional burden on
the staff caring for them.
Plan of care should include nutrition, symptom control,
psychological, social and spiritual support. Common symp-
toms requiring treatment in the ED include pain, difficulty in
breathing, noisy respiratory secretions, nausea and vomiting,
dysphagia, incontinence and anxiety.23 24
Dyspnoea and intractable pain are experienced by many
patients with end-stage heart failure, cancer and other respiratory
4 Dawood M. Emerg Med J 2019;0:1–6. doi:10.1136/emermed-2019-208632
Emerg Med J: first published as 10.1136/emermed-2019-208632 on 13 August 2019. Downloaded from http://emj.bmj.com/ on 20 August 2019 at University of Warwick. Protected by
diseases particularly in the last days of life. It is often the tipping
point for carers’ and nursing homes who feel unable to cope
with the increasing severity of symptoms and need the reassur-
ance and support of the ED. Although dyspnoea is a sign of phys-
iological disease, there is a growing appreciation in palliative
medicine of the non-respiratory aetiologies particularly anxiety
and emotional angst that can exacerbate breathing problems,
intensifying the distress for the patient and carers.41
Systemic opioids are the most frequently used drug treatment
for the symptomatic management of dyspnoea. Morphine is
recommended by the WHO and is included in their evidenced-
based list of essential medicines in palliative care which was
updated in 2013. Morphine has the advantage of relieving
both pain and anxiety. However, significant barriers still exist
to the appropriate use of opiates in the EoLC.42 The evidence
suggests suboptimal prescribing is due to knowledge deficits,
attitudinal concerns and unfounded perceptions of opiates
hastening death.43 Older patients particularly, are prescribed
fewer opiates.44 Although treating the physiological signs and
symptoms of pain and breathlessness is a priority for patient and
carer comfort and relief, it is important not to overlook other
possible causes of such distress but to view it through a wider
biopsychosocial prism.45
Non-pharmaceutical measures can be equally effective and
should not be dismissed in the face of pain and distress. A
comfortable fresh bed, adequate pillows and sips of water go a
long way to relieving distress. But the qualities most appreciated
by patients and carers are empathy, compassion and kindness
from the clinical staff.
Nursing care should include regular repositioning as well as
personal hygiene and mouth care. Poor intake of oral fluids can
copyright.
result in a very sore mouth and tongue so constant mouth care/
moistening is imperative. The reason for any intervention such
as intravenous cannulas or urinary catheters must be justified for
patient comfort and clearly explained to the patient, their family
and carers. Where possible, the Palliative Care Team should be
called for advice and to review the patient, they have specialist
expertise that may benefit the patient and help clinical staff
caring for the patient.
Cultural needs
Many societies have become more diverse in recent years due
to the migration of people for economic and political reasons
including war.46 In a multicultural society, death and dying are
understood and experienced within a complex mosaic of cultural
and religious meanings. It is important to be culturally sensitive
to diverse practices but not make assumptions, establishing the
wishes of the patient and family takes priority as action or omis-
sion can cause upset.
Where there are language barriers, best practice advocates the
use of interpreters,47 but in the end of life situations, patients
may prefer to have their families interpret for them. It is essen-
tial that all EDs maintain up-to-date lists of chaplains and spir-
itual leaders of all denominations. Staff should offer to call the
Chaplin/Priest/Imam/Rabbi or spiritual leader at any time if that
is what the patient desires.
Organ donation
Organ donation is a core competency in emergency medicine as
is the management of patients in the final stages of life.48 The
gap between the availability of organs for donation and patients
desperately in need of transplants remains high and age is not
a contraindication to organ donation. Yet many older patients

particularly those who have sustained brain injuries (medical or
traumatic) that  are clearly not survivable may have been other-
wise healthy and may be suitable donors. This potential should
not be overlooked or dismissed, emergency physicians have a
vital role in identifying and referring dying patients where organ
donation is a possibility and the specialist nurses for organ dona-
tion should be contacted for advice and to approach family and
carers.49 ED physicians should be aware and refer to their local
policies on organ donation.
Recommendations
►► Developing the EoLC skills and adopting a proactive
approach to improving EoLC is essential to ensure patients
die with dignity.
►► Appointing an EoLC/Bereavement lead and having a desig-
nated space that provides privacy and dignity is a great start
but this will only be effective if staffing levels are sufficient
and all clinical staff have training in EoLC.
►► Including advanced communication skills and palliative care
competencies in the specialist medical and nursing curricu-
lums is essential.
►► Multidisciplinary training and closer working with in-hos-
pital and community palliative care teams should be
encouraged.
►► Senior clinicians should be included in specialist teaching so
they can lead the changes necessary to improve EoLC in the
ED.
►► Most of all, a move away from DNAR to goals of care will
reassure patients and lessen the angst experienced by physi-
cians and patients in these difficult conversations.
Conclusions
Delivering good EoLC can be a challenging process in EDs as
it is often associated with practical, ethical and legal dilemmas.
However, as demands for emergency care continue to rise along-
side a shortage of inpatient beds, it is essential that ED clinicians
move towards an acceptance that provision of EoLC is a neces-
sary and appropriate purpose of the ED. Making the EoLC a
core function for emergency care amounts to a paradigm shift
which will not happen overnight. But it is a goal we must work
towards to ensure the ED is not ‘the wrong place to die’ and
the memory for those who live on is the best it can be. It is the
greatest privilege for clinicians to have the opportunity to care
and comfort a patient in the last hours of their life; we can, with
the right mindset and resources do this well.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
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