Death and dying - Clinical Tree

Essentials

1
Death and management of the dying process is core business for emergency medicine.
2
Death in the emergency department can be either sudden and unexpected or the natural and expected evolution of a disease process.
3
Emergency physicians have a responsibility to understand the principles of a ‘good death’ and to manage departmental deaths in alignment with these principles.
4
Communication skills for discussing death and dying are part of the skill set of an emergency physician.
5
Persons undertake advance care planning to support best care at the end of life. Personal wishes and values supporting such decisions may be available for viewing at the time of admission to the emergency department. Such considerations may support a ‘good death’ or may complicate clinical decision making and resuscitation.
6
How a death is managed in the emergency department has a profound impact on the next of kin and their grieving process. Emergency physicians should understand and be able to manage their role in establishing a normal grieving process for bereaved families.
7
Organ donation should be considered for all patients where death is expected. Suitability for donation should be discussed with an organ donation specialist.
8
Local statutory obligations for coronial reporting must be well understood and observed.
9
The emotional health of emergency medicine practitioners should be monitored and external assistance sought when appropriate.

Introduction

For most people, the normal expectations are that they will live a full life, that parents will pre-decease their children and that the dying person will be able to deal with any unfinished business and die surrounded by loved ones, as portrayed in the media. There is an expectation that death will be natural, peaceful and, for the majority, free of pain. In marked contrast to such expectations is the unexpected death of a loved one at an emergency department (ED), where sudden unexpected and violent death is not uncommon.

Death and dying patients are an inevitable part of emergency medicine practice. In 2014 to 2015 a total of 4916 people died in Australian EDs before they could be admitted. These deaths can be either sudden and unexpected or the natural evolution of a dying process. Sudden unexpected death from trauma or rapid, overwhelming disease processes is somewhat unique to emergency medicine; the management of patients and families in this situation is something with which all emergency physicians must be familiar. The management of the patient dying from a life-limiting illness in the ED calls for a skill set different from that needed to deal with an unexpected death, but it is just as important. For some, facing a surviving family or counselling a dying patient may symbolize failure in the battle against disease; however, it is a privilege and, done correctly, can be an extremely fulfilling part of emergency medicine practice. In such situations, one does not have the benefit of a long-standing doctor-patient relationship. The support and mutual understanding that are the cornerstones of family practice are missing; therefore rapport must be forged in the heat of the moment. Families need space and time to come to grips with a death, but both are limited in the ED. Access block and overcrowding should not preclude sensitive, empathetic grief management.

To follow the strain and pace of a difficult resuscitation with the grace and emotional energy required to care for a family requires considerable effort. Emergency physicians also have a duty of care to the survivors, who deserve compassion as much as the recently deceased.

Similarly, management of the patient dying at the end of a life-limiting illness can be a complex and challenging task. Patients and their families in this setting attend the ED for many reasons, including fear, unrelieved symptoms and the inability to access appropriate services. This does not always represent a failure of the health system but is determined by clinical complexity, as an ED is sometimes the only place that can deliver the level of care required. An understanding of the concepts of advance care planning is required. Clinicians must be familiar with local processes, as these may vary from state to state (see Chapter 21.6 ). ED clinicians should have sufficient knowledge of local palliative resources to enable advocacy roles for patients with special needs and foster partnerships with local care providers to facilitate transition into other services.

The concept of a good death is recognized widely and based on key themes ( Box 21.1.1 ). These apply equally to unexpected and expected deaths. Death in an ED may violate some or all of these principles. Emergency physicians should apply these concepts to practice as best they can within the constraints of a busy, crowded ED.

Box 21.1.1

Ten key elements of best care for the d y ing

From Ellershaw J, Lakhani M. Best care for the dying patient. BMJ 2013;347:f4428, with permission.

1.
The fact that the patient is in the last hours or days of life should be acknowledged by the multidisciplinary team and documented by the senior doctor responsible for the patient’s care.
2.
Where possible and deemed appropriate by the relative, carer or advocate, recognition of the imminence of death should be shared with the patient.
3.
The patient and relative, carer or advocate should have the opportunity to discuss the patient’s wishes, feelings, faith, beliefs and values.
4.
Anticipatory prescribing for symptoms of pain, excessive respiratory secretions, agitation, nausea and vomiting and/or dyspnoea should be in place.
5.
All clinical interventions should be reviewed in the best interest of the patient.
6.
There should be a review of hydration needs, including the commencement, continuation or cessation of clinically assisted (artificial) hydration.
7.
There should be a review of nutritional needs, including the continuation or cessation of clinically assisted (artificial) nutrition.
8.
There should be a full discussion of the plan of care with the patient where possible and deemed appropriate and with the relative, carer or advocate.
9.
There should be regular reassessments of the patient at least every 4 h.
10.
Care of the patient and relative, carer or advocate immediately after death should be dignified and respectful.

The better the memory of the death, the more likely the bereavement will be normal. The quality of care provided may prevent significant morbidity, as pathological or unresolved grief can lead to later problems with physical and mental health.

The process of dying

Diagnosing dying

Death does not occur at a finite moment. Cardiac death, cerebral death, brain-stem death and cellular death form a continuum over minutes or hours. Considerable effort has been directed to the core recognition of diagnosing death. Legal definitions for diagnosing brain death, circulatory death and the staff involved are outlined in the relevant transplantation and organ donation acts in various jurisdictions. This has been done largely to facilitate organ transplantation.

There has been little research in the area of diagnosis of the dying process and the part that emergency physicians may play in this. The diagnosis of dying is a skill best exemplified by palliative medicine specialists. The timing of the death can be hard to estimate and comes with experience. A diagnosis of the likelihood of dying sets appropriate goals of care and so enables the emergency physician to engage families in preparation and allows patients to be supported with appropriate systems of care. Where possible, the patient should be enabled to maintain some control and may be able to plan for the time he or she has remaining (see Chapter 21.6 ).

Managing the dying process

When the point of dying is reached, the practitioner must be acutely aware of the dying person’s needs. Although physical needs, such as analgesia, are relatively easily met, other domains can easily be ignored.

For patients whose death is inevitable or not unexpected, guidance documents published by the International Collaborative for Best Care of the Dying Person can be tailored to local conditions and can help to support clinicians. These care documents can be instituted in the ED. This tool focuses team care on the optimal relief of the dying patient’s symptoms and the avoidance of unnecessary interventions. The intent is to provide hospice-level care in other clinical settings. At this point, the principles of a good death previously described can act as an aspirational target as emergency clinicians attempt to rationalize the care they provide.

A large family may need significant space, which can interfere with the routine work of the ED; ideally a private room should be available. The clinicians’ role then includes focusing on physical comfort, symptom management, and the privacy of the patient and family.

Death

Family members should be encouraged to be present during resuscitation efforts. A senior support person should be available for the family if at all possible during this time. As survival becomes increasingly unlikely, family members can be encouraged to be involved in decision making around resuscitative efforts and whether or not they should continue. After death, families should be encouraged to view, touch and talk to the deceased. It is well recognized that this facilitates the grieving process. They will remember these moments for the rest of their lives. Participation in the resuscitation process and in the decision to end it can be helpful.

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