Are accident and emergency departments a good place to die?

Accident and Emergency
17 Dec 2010 14:28:00.000


Patients in need of supportive and palliative care need to be given special attention in hospital emergency departments, according to new research.

Palliative care for terminally-ill patients is often neglected because A&E departments are geared towards emergency medicine and resuscitation of patients in critical need, the University of Nottingham study found.

The findings suggest a combination of factors can result in palliative care needs being neglected. They also suggest that medical professionals should be given more training to help them meet the complex needs of growing numbers of older people, and people with terminal illnesses, who are attending hospital emergency departments for supportive end-of-life care.

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Published in the Annals of Emergency Medicine, the study warns that the UK’s ageing population will place increasing demands on emergency departments in terms of palliative and end-of-life care in the years to come.

The research, conducted at The University of Nottingham and funded by the Centre for Social Research in Health and Healthcare, was based on 1,000 hours of observation, plus interviews with health care professionals, patients with terminal illnesses and their relatives.

Researchers identified two trajectories for dying patients: the spectacular — applied to those who are candidates for intensive life-preserving treatment — and the subtacular, applied to those who are not, including patients with terminal illnesses.

Terminally-ill patients and their families reported less satisfaction with their care than patients whose death was unexpected. This was because some staff tended to distance themselves from these patients, in part because emergency care is prioritised toward resuscitation. Many staff members interviewed said they felt unprepared to care for the dying in the emergency department, either because of a lack of resources or because they receive so little training in palliative care.

Professor Roger Murphy, of the Centre for Research in Schools and Communities at the School of Education, University of Nottingham, was a co-author of the study.

Professor Murphy said: “This groundbreaking research has revealed some quite startling findings about the extent to which emergency staff are struggling to provide appropriate end of life care for a significant proportion of people who die in that setting.

“Our study has highlighted the needs of patients, who in increasing numbers access hospital emergency departments, requiring subtacular — rather than spectacular — care, often towards the end of a terminal illness. Such deaths provide a real challenge for staff whose priority is saving and prolonging life rather than providing supportive palliative care.

“As an inter-professional team we see this as pointing to important priorities for future professional learning and staff development.”

Dr Cara Bailey, the lead author, has moved to the University of Birmingham’s School of Health and Population Sciences, since conducting this study.

Dr Bailey said: “Patients and their families receive a lot of attention and support in the emergency department when there is an unexpected acute medical illness or a sudden, often traumatic event that results in death, but we also need to focus on patients who are dying as a result of a terminal or life limiting illness who equally need attention and support during an emergency crisis.

“While the emergency department is not designed for end-of-life care, the reality is that many patients in this category go there for help, sometimes not realizing this is the end. Emergency resources are focused on saving lives, which tends to shortchange the patients who have terminal illnesses.

“Death, dying and bereavement are daily occurrences in the emergency department, but it is a sadly neglected area of research, professional development and practice. With an increasingly aging population, more people are living longer, and slower dying from chronic illness is becoming the norm. The ‘subtacular’ death is becoming more prevalent in our society.

“Collaborative effort among policymakers, educators and health care professionals is needed to improve how end-of-life care is provided in the emergency department, not only for patients but also for their families.”

The study, ‘Trajectories of End-of-Life Care in the Emergency Department’, is published online in the Annals of Emergency Medicine.

— Ends — 

Notes to editors: The University of Nottingham, described by The Times as “the nearest Britain has to a truly global university”, has award-winning campuses in the United Kingdom, China and Malaysia. It is ranked in the UK's Top 10 and the World's Top 75 universities by the Shanghai Jiao Tong (SJTU) and the QS World University Rankings.

The University is committed to providing a truly international education for its 39,000 students, producing world-leading research and benefiting the communities around its campuses in the UK and Asia.

More than 90 per cent of research at The University of Nottingham is of international quality, according to the most recent Research Assessment Exercise, with almost 60 per cent of all research defined as ‘world-leading’ or ‘internationally excellent’. Research Fortnight analysis of RAE 2008 ranked the University 7th in the UK by research power.

The University’s vision is to be recognised around the world for its signature contributions, especially in global food security, energy & sustainability, and health.

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Story credits

More information is available from Professor Roger Murphy, Centre for Research in Schools and Communities, School of Education, University of Nottingham, on +44 (0)115 8467201,; Jenni Ameghino, University of Birmingham Press Office, on +44 (0)121 4158134
Tim Utton

Tim Utton - Deputy Director of Communications

Email: Phone: +44 (0)115 846 8092 Location: University Park

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