End of Life Care in the Emergency Department
Caring for patients in the emergency department who are reaching the end of life is complex and at times difficult, but also a very rewarding part of your clinical practice when done well. Decisions and conversations with relatives and carers of patients about resuscitation status, advance care plans and patient wishes can be difficult and should be handled in a sensitive, compassionate and professional manner. Prescribing for a patient who may be imminently dying and organising death certification may be an area you are uncomfortable with.
For these reasons we have pooled a number of resources with quick links to help you navigate the relevant areas.
Curative care or comfort care
To assist in the conversations you may have we provide a link below. We know that for the most part the decision is clinical but a delicately handled conversation can relieve anxiety and avoid misunderstandings or unrealistic expectations further along the clinical path. It is imperative to make a clear decision and communicate it to all treating clinicians as well as document well and clearly in the notes. Limitations must be clearly spelled out and be consistent with information you have communicated.
Using Resuscitation Plans in End of Life Decisions
A Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures which documents other aspects of treatment relevant at end of life.
The Policy Directive Using Resuscitation Plans in End of Life Decisions published by the Office of the NSW Chief Health Officer describes the standards and principles relating to appropriate use of Resuscitation Plans by NSW Public Health Organisations for patients aged 29 days and older.
Under the Policy Directive, all Public Health Organisations must:
- Adopt the state Resuscitation Plans (adult and paediatric) – see Forms below for examples. These should replace similar existing LHD forms (e.g. No CPR Orders, Not for Resuscitation Orders)
- Incorporate evaluation of whether Resuscitation Plans were completed into death audit protocols.
As a person reaching the end of life begins to deteriorate their regular medications may not need to be administered. The important medications to remember charting before the patient leaves the emergency department are for pain, anxiety/sedation, increased secretions and nausea/vomiting. Consider withdrawal which may occur with narcotics, benzodiazepines, SSRI and similar medications and even b-blockers, the withdrawal of these and some other medications may lead to unnecessary distress.
Last Days of Life Toolkit
To improve and support the care of dying patients, the Clinical Excellence Commission has developed a last days of life toolkit.
The toolkit provides tools and resources to ensure all dying patients are recognised early, receive optimal symptom control, have social, spiritual and cultural needs addressed, both patient and families/carers are involved in decision-making, and bereavement support occurs. It has been specifically developed for use by generalist clinicians and is not intended to replace either local Specialist Palliative Care guidelines or advice given by Specialist Palliative Care clinicians.
Certification of death
This part gives information on verifying and certifying death, cases to report to the coroner and cremation.