Context
Emergency Medicine clinicians are highly trained to resuscitate and stabilise emergencies and actively treat illnesses. However, patients approaching the end of their lives need a different focus: support to live as well as possible until they die, and to die with dignity when appropriate1.
Achieving this is challenging. Balancing aggressive curative interventions against more palliative approaches when given incomplete information and an uncertain prognosis, and having to communicate rapidly changing situations to patients and families at distressing times, is difficult2.
Emergency Medicine clinicians therefore need to be skilled at recognising dying patients, exploring goals of care with them and their relatives, helping them achieve those goals within their remaining time, identifying and managing distressing symptoms, all while acting within legal and ethical frameworks3.
Is the ED the right place for palliative care?
In the pressures of our work environment, recognising that someone is dying can be difficult4. However, our brief relationship with a patient can position us uniquely to have a more objective perspective of their overall illness trajectory that that of primary teams5. Pausing to consider a patient holistically at the first point of contact in the ED can add value immediately to their care and help prevent inappropriate escalation later in their hospital journey.
While a crowded emergency department, where boarding of patients is becoming more common, may not be the ideal location for someone near the end of life, early recognition by EM clinicians can also help prioritise these individuals for transfer to a calmer environment, either within the ED or elsewhere in the hospital.
Furthermore, as the population ages and multimorbidity becomes more common, we will see increasing numbers of patients with chronic life-limiting illnesses presenting with acute deteriorations or health crises, especially as the ED is always available when alternative care pathways don’t exist3. While the majority of patients express a wish to die at home, less than half will do so, and ultimately most family members (74%) felt that hospital was the right place for their loved one to die rather than at home4, 6-8. It is important therefore that we are familiar with palliative care principles to be able to provide them with the excellent quality care they need at a critical point in their lives.
Learning Bite
High quality palliative care is essential for patients attending the ED who are approaching the end of their lives. Emergency medicine clinicians are frequently best placed to commence this care in a timely manner.