Abstract
The role of the Emergency Provider (EP) is to appropriately diagnose and stabilize acute life-threatening injuries and illnesses. Despite good intentions and optimal medical therapies, some patients will not survive their ED course; others will die in the hospital, usually in the intensive care unit (ICU) days after admission. Medicare data show that over one-third of patients who die receive medical care in the ED and ICU during their last 6 months of life. Patients overwhelmingly prefer to die at home. Unfortunately, studies show that 38% of people die in the hospital, specifically 22% occur in the ICU, often times while receiving maximum levels of care. Since many of these patients are admitted through the ED, it is essential for an EP to be proficient with end-of-life (EOL) care.
The American Academy of Hospice and Palliative Medicine describes that the goal of Palliative Care (PC) is to “prevent and relieve suffering and to support the best possible quality of life for patients, facing life-threatening or debilitating illness, and their families, regardless of the stage of the disease or the need for other therapies.” PC is not the same as hospice care. Hospice care is a subset of PC focusing on patients with terminal illness and a predicted life expectancy of 6 months or less who forego therapeutic medical interventions in favor of comfort and quality of life.
In 2014, the American College of Emergency Physicians (ACEP), as part of the Choosing Wisely campaign, recommended that EPs “(d)on’t delay engaging palliative and hospice care services in the Emergency Department for patients likely to benefit.” A recent study of ED-initiated PC in advanced cancer patients demonstrated improved quality of life (QOL) with no negative effect on survival. Despite these recommendations and findings, only 18% of residents and medical students receive formal training in EOL care. The goals of this chapter are to review medical ethics, discuss the concept of shared decision-making and goals of care, explore communication strategies for EPs, and examine the concept of medical futility.
“Our ultimate goal, after all, is not a good death but a good life to the very end.”
—Atul Gawande
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Teno, J. Facts on Dying March 19, 2004. Center for Gerontology and Health Care Research, Brown University. 2006. http://www.chcr.brown.edu/dying/2001DATA.HTM
Loh AZ, Tan JS, Lyn TY, Krishna LK, Goh CR. Places of care at the end of life: what factors are associated with patients’ and their family members’ preference? Am J Hosp Palliat Care. 2016;33(7):669–77.
Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638–43.
American Academy of Hospice and Palliative Medicine (AAHPM). AAPHM home page. Available at: http://www.aahpm.org/about/college.html. Accessed 23 Aug 2017.
Grudzen C, Richardson L, Johnson P, Hu M, Wang B, Ortiz J, Kistler E, Chen A, Morrison S. Emergency-department –initiated palliative care in advanced cancer. A randomized control trial. JAMA Oncol. 2016;2(5):591–8.
Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685–95.
American College of Emergency Physicians. Policy statement: code of ethics for emergency physicians. Approved January 2017.
Zieske M, Abbott J. Ethics seminar: the hospice patient in the ED: an ethical approach to understanding barriers and improving care. Acad Emerg Med. 2011;18(11):1201–7.
Yadav K, Gabler N, Cooney E, Kent S, Kim J, Herbst N, Mante A, Halpern S, Courtright K. Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Aff. 2017;36(7):1244–51.
Bernacki RE, Block SD, for the American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003. https://doi.org/10.1001/jamainternmed.2014.5271
Carlet J, Thijs LG, Antonelli M, Cassell J, Cox P, Hill N, Hinds C, Pimentel JM, Reinhart K, Thompson BT. Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical care: Brussels, Belgium, April 2003. Intensive Care Med. 2004;30:770–84.
Charles C, Whelan T, Gafni A. What do we mean by partnership in making decisions about treatment? BMJ. 1999;319:780–2.
Flynn D, Knoedler M, Hess E, Murad M, Erwin P, Montori V, Thomson R. Engaging patients in health care decisions in the emergency department through shared decision-making: a systematic review. Acad Emerg Med. 2012;19:959–67.
Wynn S. Decisions by surrogates: an overview of surrogate consent laws in the United States. Bifocal. 2014:36(1). Accessed on 9/5/2017 https://www.americanbar.org/publications/bifocal/vol_36/issue_1_october2014/default_surrogate_consent_statutes.html.
Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5):493–7. https://doi.org/10.1001/archinte.166.5.493.
Hunter JK, Dean T, Gowan J. Death with dignity: devising a withdrawal of treatment process. Br J Nurs. 2006;15(3):138–40.
Cook D, Rocker G, Marshall J, Sjokvist P, Dodek P, Griffith L, Freitag A, Varon J, Bradley C, Levy M, Finfer S, Hamielec C, McMullin J, Weaver B, Walter S, Guyatt G. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med. 2003;349:1123–32.
Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112:949–54.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2020 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Manasco, A.T., Wessman, B.T. (2020). End-of-Life Care in the Emergency Department. In: Shiber, J., Weingart, S. (eds) Emergency Department Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-030-28794-8_38
Download citation
DOI: https://doi.org/10.1007/978-3-030-28794-8_38
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-28792-4
Online ISBN: 978-3-030-28794-8
eBook Packages: MedicineMedicine (R0)