See also pp. 154–160
End-of-life issues are becoming front of mind for emergency physicians. As our population ages and chronic illness increases, we are faced more and more with patients in their final stages of cancer, respiratory or cardiac failure, and dementia. Palliative care is becoming a core part of emergency medicine training, with various US centres offering emergency medicine Palliative Care Fellowships. Other US emergency physicians are seeking additional training in the field through programmes such as the Education in Palliative and End-of-Life Care for Emergency Medicine and the Harvard Program in Palliative Care Education and Practice. In the UK, the College of Emergency Medicine Clinical Effectiveness Committee has produced a guideline for best practice at the end of life. A 2011 paper in the Journal of Palliative Medicine reported that Emergency Medicine trainees felt they needed more training in ED palliative care, particularly in management at the end of life.
This may seem paradoxical to some, as we spend much of our time trying to thwart death! However, life and death have always sat alongside each other in our ED practice. From the out-of-hospital cardiac arrest victim to the drowned child, we have always had to face failure to resuscitate and have had to inform and support devastated families (and each other) through these distressing events.
We are also frequent witnesses to those ‘near miss’ events nearing the end of life, when the person survives that episode, only to face the next one. Separated from the day-to-day care of the dying person, we may be better equipped, in some ways, to identify deterioration and the futility of active medical care. We are frequently in the position of explaining these ‘near miss’ events to family members – an opportunity to explore their knowledge and plans for the actual process of death. As many of us have experienced, this may not have been specifically broached before. It is an irony that the emergency physician, who has never met the patient and family before, may be the first medical person to specifically address the topic. It is possible that being distant from the ongoing therapeutic relationship makes this discussion easier.
In their survey of knowledge and attitudes of both emergency and oncology/palliative care, clinicians reported in this issue of the journal; Jelinek et al. identify some key issues and impediments that affect end-of-life care in the ED. They explore factors relating to the physical environment of care, the difficulties in communication with the ongoing care teams (particularly out-of-hours) and the importance attached by many of us to providing a ‘good death’.
Whereas Jelinek et al.'s paper deals mainly with cancer patients at the end of life, there might be even more urgency for discussing these issues in the very elderly population. Nursing homes were once seen as a place to die, but risk aversion and lack of planning now frequently lead to disruptive and unproductive ambulance transfers to ED. We need to recognise recurrent aspiration pneumonia in advanced dementia as a sign of a failing body and resist the temptation to treat it as a ‘community-acquired pneumonia’.
A good death requires planning and preparedness from all parts of the care chain. The family and other carers need to be apprised of the imminence of death and assisted to face the emotions and experiences that will occur when death comes. Community and subspecialist clinicians need to partner with their dying patients to ensure that they are working towards the same aims, including the avoidance of futile care.
Nursing home staff need a firm plan for the dying process, an adequate supply of medications to deal with it and an explicit agreement that allowing a ‘good death’ is not a failure of care.
Finally, emergency clinicians need to be prepared to take leadership in managing the dying process, to modify the physical environment of the ED to support this and to value the ability to manage end of life as a core skill. For all that we might wish that the death occurred elsewhere, ED is the final common pathway for many difficult health issues. Our ability to manage complex issues across the spectrum of illness makes us well suited to this task, which our patients both need and deserve.