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


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
School of Nursing, Queens Medical Centre, The University of Nottingham, Nottingham, UK. c.bailey.2@bham.ac.uk
Cara
C
Bailey
Roger
R
Murphy
Davina
D
Porock
D000293:Adolescent; D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D003258:Consumer Behavior; D004636:Emergency Service, Hospital / Q000592:standards; D005190:Family / Q000523:psychology; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D008297:Male; D008875:Middle Aged; D013315:Stress, Psychological / Q000209:etiology / Q000523:psychology; D013727:Terminal Care / Q000523:psychology / Q000592:standards; D006113:United Kingdom; D000078329:Workforce