Article Review: Obstacles to end of life care in the Emergency Department Lydia Pope, RN

Article Review: Obstacles to end of life care in the emergency department

Lydia Pope, RN, Nurse Resident - Emergency Department

Editor’s Note: Ms. Pope wrote this paper as part of her Carilion Nurse Residency experience.

Article Reviewed: Beckstrand, R. L., Corbett, E. M., Macintosh, J. L., Luthy, K. E., & Rasmussen, R. J. (2019). Emergency Nurses’ Department Design Recommendations for Improved End-of-Life Care. Journal of Emergency Nursing, 45(3), 286-294. doi:10.1016/j.jen.2018.05.014

Emergency Department (ED) nurses are required to provide end of-life-care in what is commonly thought to be a busy and impersonable environment. In 2013 alone, it is estimated that over 130 million patients died in EDs across the U.S. (Beckstrand et al., 2019). The sheer number of deaths occurring in EDs requires reflection concerning the nature and quality of these experiences. Beckstrand, et al. (2019) surveyed 158 U.S. ED nurses who had taken care of at least one dying patient to identify variables that impeded or assisted an ED nurse’s ability to provide end of life care. These nurses were asked to share their personal experiences regarding the care of these patients as well factors that negatively or positively impacted these events (Beckstrand et al., 2019).

Through the shared experiences of ED nurses, Beckstrand et al. (2019) identified three major obstacles to providing end-of-life care to patients in the ED:

1. 2. 3. limited space to allow room for both staff and family members limited privacy for the dying and their loved ones lack of areas for appropriate body stowage after death.

The survey respondents noted that many ED rooms are extremely cramped, and nursing staff often “trip” over other staff members, medical equipment and family while attempting to care for dying patients, particularly in acute or code situations. Large resuscitation bays may be unavailable for palliative use, and even if empty, these rooms must be kept open for possible in-coming patients (Beckstrand et al., 2019). This flaw in department layout at some organizations has the potential to create a challenging environment to provide care efficiently and respectfully while simultaneously including the family should that be their wish. Family members may need to wait in nearby rooms or often must stand in the hall to observe critical moments or resuscitation attempt, and grieving family members may only be allowed to the bedside one at a time (Beckstrand et al., 2019). Further, curtained rooms and the loud nature of the ED may inhibit the privacy of the dying individual and their loved ones. Patients and their family members often must contend with noisy and sometimes intoxicated and distracting patients in adjacent rooms. Private information may be overheard by others in the department (particularly in curtained rooms), and even rooms near nurse’s stations may encroach upon patient privacy as laughter and conversation from staff may appear insensitive during end-of-life situations (Beckstrand et al., 2019).

Further, many of the surveyed nurses stated that stowage of the deceased was also an issue when providing end-of-life care in the ED. Many EDs are not equipped with areas in which the deceased can be stowed prior to transport to the hospital’s morgue while necessary documentation and post-mortem care is completed, as rooms are needed to turn over for the next patient. Per the authors, this has led to improper stowage of bodies. One participant of the study recounted that at their facility, a body was once stored in an elevator which was thought to be disabled. The elevator, however, was not properly disabled and locked, and a family member discovered the body ascending and descending the elevator shaft (Beckstrand et al., 2019).

Proper areas for bodies appear to be a pressing and disturbing issue for some EDs. In reflection, the study identified several major obstacles to end-of-life care; however, the authors did not include a plan to apply or utilize the collected information. A very small sample of nurses were surveyed, which limits interpretation for a broader population. Further, the article only briefly mentioned variables that positively impacted nursing care at the end-of-life, thus lacking a true solution. While surveys are a useful tool, satisfaction surveys of patient families could further reveal obstacles to end-life-care in the ED. The results of the article raise further questions regarding the end of life in the ED and prompt further research

Having been a nurse for only a year, my personal experience providing end-of-life care in the ED is relatively limited. My exposure to such situations has largely been positive thanks to the excellence in practice of my fellow nurses, ED providers, and the indispensable work of our ED patient representatives. When comparing the determined obstacles of this study to what I have witnessed in Carilion’s ED, there is thankfully little overlap. At times, space can be a limiting factor when providing end-of-life care, and families (either by choice or due to necessity) may not be present at the bedside. This is remedied by good communication and frequent updates between providers and family, often facilitated by a patient representative dedicated to caring for the family. Maintaining patient privacy has at times been a challenge depending on where the patient has been roomed. Curtained rooms are less desirable in these situations (as expressed by the study participants), but there is a definite effort made to place these patients in rooms with doors when possible. Carilion’s ED also has access to a palliative room which provides patients and family members a more secluded and quiet area to receive care.

The most significant obstacle to end-of-life care I have noted in Carilion’s ED is the pace of ED work. Due to the great diversity of patients treated in EDs, ED nurses (as well as other members of ED staff) must act as a jack of all trades in a fast-paced, ever-changing environment. However, ED staff may not have the specific end-of-life training or resources to function at the same caliber as units dedicated to hospice and palliative populations. In addition to caring for dying patients and their families, ED staff must continue to monitor, assess and treat a full patient load. Delicately balancing these patient assignments can be difficult and even emotionally distressing for both staff members and patients. The mitigation of this issue would be multifaceted and would require the input and expertise of all members of ED staff. Further education regarding end of life care could enhance the ED’s ability to care for these patients. Exploring partnerships between palliative and hospice units to assist the ED in caring for these patients may aid in relieving pressure on ED staff and promote optimal care of patients during the end of life. Surveying our staff would provide more insight to other possible obstacles to providing end-of-life care in our ED as well as means by which to overcome these obstacles.