On death and dying in emergency department

Whatever our beliefs, we all die. And in ED we are exposed to death frequently relative to most professions. But managing death and dying is complex. In this Trainee Focus editorial, I chart the changing nature of death in Western society and the exposure and challenges faced by ED clinicians. No solutions are put forward. A 2019 Australian Bureau of Statistics study1 found 51% of deaths in Australia occurred in hospitals, 30% in residential care facilities and 15% at home. Indeed, in high-income countries, the transition of death from home to healthcare facilities has contributed to the diminishing role of family and community as traditions and knowledge around dying recede.2 And in doing so, we are part of a society that is shielded from the process and perhaps less comfortable with death than ever before. Within a century, there have been significant shifts in the nature of death in high-income nations: deaths from chronic non-communicable disease have come to predominate, participation of doctors has proliferated, detection of terminal disease and the length of the dying phase has swelled as medical technologies advance, years lived without good health have increased, all the while death rituals devalue and familiarity and participation of family diminishes.2-4 Religious, philosophical and spiritual beliefs fundamental to the human experience of dying have forfeited ground in place of scientific progress and the hospital's fight against death. As medical interventions have advanced both in capability and quantity, there has not been a commensurate weight on conversation around the shared understanding of death's inevitability by the health system and individuals.4 A complex milieu of sociocultural, political, and economic changes has determined the way death is now treated. Dying has become one of the costliest healthcare events.2, 5 The Lancet Commission on the Value of Death2 describes the harrowing paradox of this resource consumption as preventable death and undertreated pain and suffering prevail in low-resource settings. Palliative care services have better articulated a holistic patient-centred approach, and can cost-effectively improve quality of life and diminish symptom burden.6 But its provision globally has also been inequitable, with alleviation of pain being unmet in populations where access to simple analgesia is poor and funding for palliative services considered a luxury competing with sterner health priorities.6 Less than 0.1% of ED presentations culminate in death in Australasian EDs. In 2022–2023 there were 6161 deaths in Australian EDs, and 1713 people declared dead on arrival.7 In 2021–2022, 838 deaths were recorded in Aotearoa New Zealand EDs (National Non-Admitted Patient Collection [NNPAC], email communication, 23 January 2024). Not captured in this data are many more patient attendances during which end-of-life discussion is a pivotal intervention without the patient passing away in ED. Death occurs through conflict, accident, natural disaster, pandemic, violence, suicide, neglect or disease.2 Our exposure in ED, classified in many possible forms, is summarised in Box 1 through the lens of standardised death reviews. The categories are each likely to elicit distinct responses by health systems for quality improvement. Death in ED can be uniquely arduous, especially if unexpected, traumatic, involving young people, or secondary to iatrogenesis. The unexpected death may have significant ramifications. Bereaved family members are likely to be less supported when clinicians are reckoning with their own well-being. Early input of social workers is invaluable. Debriefing activities serve learning, team-building and pastoral care purposes in rapid time. Legal requirements must be fulfilled, be it reporting to the coroner, intrahospital executive notification, and for Severity Assessment Code one incidents, timely jurisdiction-level notification. Revisiting clinical events through department death reviews are another means of extracting learning opportunities and actions for improvement. Indeed, morbidity and mortality (M&M) meeting delivery has been added as an ACEM training requirement, thus, Trainee Focus has invited Goulding9 to explore the nuances of executing the M&M. Delivering end-of-life care for those anticipated to pass away is a requisite skill in an emergency clinician's armoury and Trainee Focus continues to advance articles on its importance. Mooney10 reflects on the holistic benefits of completing the Clinical Diploma of Palliative Medicine, including cultural aspects of care for dying Aboriginal and Torres Strait Islander patients. Carlin et al.11 introduced a previous Trainee Focus issue dedicated to end-of-life care including relevant ACEM recommendations and legal provisions. Bertenshaw and Clark12 discussed practical tips for delivering palliative care in emergency contexts. Philpot13 added pragmatic advice on how to discuss non-beneficial treatment. Arguments in favour and against goals of care being discussed with all patients were also fleshed out by van de Schoot14 and Rushton,15 respectively. Healthcare services in Australia and Aotearoa New Zealand have expanded to include provisions for assisted dying. Although not practised in ED, emergency clinicians may become Voluntary Assisted Dying (VAD) practitioners and patients in the department may expect our familiarity with the referral process. Aotearoa New Zealand and all states in Australia have legalised VAD. The Northern Territory is in a consultation phase about introducing VAD and the Australian Capital Territory's draft legislation is undergoing parliamentary inquiry before becoming law. In this issue, Graves16 reflects on the VAD experience 12 months on from its introduction in Queensland and the steps to becoming a VAD practitioner. There are complexities to managing dying patients that clinicians may be expected to overcome, which are further magnified in ED. I acknowledge that omitted here is commentary on the personal journey of the patient and their grieving families, which is of utmost importance and the motivation for these reflections to optimise our care. Death has shaped culture, history, arts and given rise to religions. Although far from the mainstay of our paediatric assessment, within the developmental milestones is a grasp of life's finitude expected around five to six years old.17 And a lifetime thereafter is lived with the tension of this knowledge. The prima facie complexity of us managing death is its significance in all our lives. Contributors to why care of the dying is complex in ED are described in Table 1. The speed and rigour of delivering emergent medical assessment and treatment to large populations is at odds with the slow, relational, and spiritual elements that take precedence in death. It is unsurprising that emergency staff do not consider the ED a good place to die.18, 19 As clinicians, we must reconcile expectations on our technical expertise, which we are consistently tested, benchmarked and adjudicated for our worthiness, with the humanistic and ethical care integral around death, for which we are arguably unselected for and certainly lesser trained. There are many reasons why even in our high-exposure profession we can lack confidence in managing the dying patient. In the unforeseeable future we may work in a society where the value of dying as a fundamental human experience is embraced and death is disarmed of its novelty, strangeness, and tragedy. In lieu of this utopia, a timeless salve borrowed from ancient mythologies is apt – let us cherish the gift bestowed on us to care for the dying.22 None declared.