End of life care in ED

Author: Mars Christian Aragon Sta Ines / Editor: Sarah Edwards / Codes: PalC2, PalC3, PalC4, SLO1 / Published: 16/06/2025

A 45-year-old female with a history of end-stage chronic obstructive pulmonary disease (COPD), cor pulmonale and depression is brought to the emergency department (ED) by ambulance due to acute breathlessness and drowsiness.

Over the past three months, she has had multiple admissions for type 2 respiratory failure, managed with non-invasive ventilation (NIV). However, upon improvement in her Glasgow Coma Scale (GCS) score, she has consistently declined further NIV and self-discharged.

Earlier on the day when she presents in the ED, she has rapidly deteriorated, becoming agitated and increasingly breathless, prompting her husband to call for emergency assistance.

Her medications have been optimised by the medical team and although multiple discussions regarding smoking cessation referrals have occurred before, she has declined participation. Psychiatric evaluation confirmed her capacity to make decisions. The respiratory specialist team have previously offered long-term oxygen therapy and surgical options, all of which she has refused.

During prior admissions, the palliative care team discussed her prognosis and advanced care planning, resulting in the completion of a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and ReSPECT form two weeks prior.

Past Medical History

• End-stage COPD
• Cor pulmonale
• Depression

Family History

• Paternal-Stroke
• Maternal-Myocardial infarction

Social History

• Current smoker: 2 packs per day for 30 years
• Social alcohol consumption
• Married-husband is primary caregiver
• Wheelchair-bound

Allergies

• None

Medications (Non-compliant)

• Salbutamol inhaler 200 micrograms QDS PRN
• Fluticasone/Umeclidinium/Vilanterol 92/55/22 micrograms inhaler, 1 puff OD
• Carbocisteine 750 mg TDS
• Sodium Chloride 0.9% nebulizer solution, 2.5–5 ml QDS
• Azithromycin 250 mg three times weekly
• Sertraline 50 mg OD

Examination

• A– No obstruction, dry oral mucosa
• B- RR 26 O2 sats 85-88% on Venturi mask
  symmetric chest expansion, decreased breath sounds at lung bases, wheezes central and peripheral cyanosis
  Chest x-ray- barrel-shaped chest, hyperinflated lungs, haziness and reticular markings at both bases (no changes from previous imaging)
• C- BP 150/90 HR 103 normal heart sounds
  ECG, sinus tachycardia
  abdomen soft and non-tender; full and equal pulses
  capillary refill time <2 seconds
• D- GCS 14-15 (fluctuating) otherwise, normal neurological examination, PEARL 2–3 mm BMs 9
• E- Temperature 36.5°C, no skin changes or rashes, cachectic appearance

Two hours post-admission, her condition deteriorates despite addressing reversible causes. Anticipatory medications are administered, and the patient dies four hours after arrival to the ED.