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  • Writer's pictureErin Hackett

A nurse researcher's journey into end-of-life care in the emergency department

What began as a data-driven endeavour gradually revealed itself as a profound exploration of humanity. This retrospective cohort study involved working with the stories of patients aged over 65 who passed away within 48 hours of triage. These patients were more than statistics; they were real people with unique life journeys and stories. Some of them might have been neighbours or friends or the lady who lived down the road. Their lives and memories intertwined with the researchers, evoking a deep sense of empathy. As the stories of these individuals were unveiled, so too were their past and final moments.

At the core of this exploration lay a fundamental question: How do emergency clinicians recognise patients at the end of life and implement timely measures in their final hours that support a good death? In the context of healthcare, a good death is an approach that prioritises the physical, emotional, and spiritual well-being of the individual during their end-of-life journey. It encompasses the provision of comfort, dignity, and support to the patient and their loved ones as they navigate this profound transition. However, the essence of a good death ultimately hinges on one critical element—preparation. The research findings unveiled various patient trajectories towards the end of life, including unexpected life-limiting emergencies, acute exacerbations of chronic diseases, and patients gradually progressing towards the end of life. Many of them had engaged in advanced care planning, and several had a history of previous ED presentations or hospitalisations within the preceding 6 months. Identifying and addressing this subset at triage for goals of care discussions is crucial.

Delving into the intricacies of the patients' last 48 hours in this world involved a deep dive into the last six months of their life, focusing on understanding these patient's healthcare values. They represented stories of good deaths, marked by love and acceptance, contrasting with stories of bad deaths, characterised by unpreparedness. Yet either journey underscored the significance of embracing our existence and mortality.

The ED offers a valuable window for symptom control planning. Poor symptom management at the end of life has been identified as a significant cause of distress to both patients and caregivers. Our findings indicated that pain assessment and management in the ED were common for individuals at the end of life. However, the use of medication for alleviating other symptoms like dyspnea, anxiety, or agitation was less frequent. With each patient story, a profound connection to those who had passed away emerged. Overall, it highlighted the unwavering dedication and compassion of healthcare professionals who, in moments of vulnerability and transition, provided healing, love, and comfort to their patients.

The Book of Ecclesiastes reminds us that there is a time for everything, including a time to be born and a time to die. Reflecting on the stories of the patients, it became evident that a good death is not solely about the final moment; it is about the journey that leads us there. It is about cherishing every precious moment, nurturing our relationships, and finding peace within ourselves and with our loved ones. Moreover, it involves embracing our mortality and the disease process that leads us to our final breaths. It necessitates meeting these challenges head-on, developing a plan, and communicating it to our loved ones. ED clinicians face the challenge of providing suitable care for patients, often without knowledge of their wishes. Regularly updating patients' advance care plans at each healthcare encounter could help identify those at the end of life and prepare both patients and their caregivers.

Viktor Frankl once said, "Live as if you were living for the second time and as if you had acted wrongly the first time." This wisdom urges us to take control of our end-of-life journey and to approach the inevitable with grace and tranquillity. It is imperative that we prepare for the journey that awaits us all, one that we can navigate with a well-thought-out end-of-life plan. Openly discussing hopes, wishes, and desires for end-of-life care with healthcare professionals and family ensures that our preferences are not only heard but also respected. In doing so, we grant our loved ones the capacity to advocate for us with compassion and empathy.

You can read the full open-access research article recently published in the Emergency Medicine Australasia journal here.

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