Trajectories of end-of-life care in the emergency department.

Abstract

The emergency department (ED) is the gateway to the hospital setting. Despite the intentions from the end-of-life care strategy in the UK to improve care provision, the ED has increasingly become the access site for end-of-life support. Little attention has been given to this aspect of the work of the ED, even as the quality of end-of-life care in hospitals has become the subject of increasing concerns. We explore end-of-life care in the ED and provide an understanding of how care is delivered to the dying, deceased and bereaved in the emergency setting. Observation was carried out in a large urban ED during 12 months. This was complemented by detailed interviews with emergency staff, patients diagnosed with a terminal condition, who had visited the ED in the previous 6 months, and their relatives. Data were analyzed thematically, following the normal conventions of ethnographic research. Two distinct trajectories of end-of-life care were identified in the ED; the spectacular and the subtacular. Patients and family members experiencing end-of-life care in the ED have distinctly different care because of the nature of these 2 trajectories, frequently resulting in dissatisfaction for staff and distress and frustration for patients and their relatives. The ED is priority driven, focused on resuscitation and the prolongation of life. As a result of the consuming nature of the spectacular death, a reluctance to build relationships with the dying, and a lack of educational support, the care needs of patients in the subtacular trajectory are somewhat neglected. These trajectories can be used to identify the shortfalls in end-of-life care in the ED and raise serious concerns for policy in regard to staffing, resources, and professional development.