We propose that the palliative care team response will occur in two ways: first, communication and second, symptom management. Our experience with discussing goals of care with the family of a COVID-positive patient highlighted some expected and unexpected challenges. We describe these challenges along with recommendations for approaching these conversations. We also propose a framework for proactively mobilizing the palliative care workforce to aggressively address goals of care in all patients, with the aim of reducing the need for rationing of resources.
BACKGROUND: There is a paucity of data to predict early death or futility after trauma. The objective of this study was to characterize the laboratory values, blood product administration, and hospital disposition for patients with trauma who died within 72 h of admission.
METHODS: All deaths within 72 h of admission over a 5-y period at a level I trauma center were reviewed. Blood transfusion within the first 4 h of arrival and patient disposition from the emergency department to the operating room (OR), surgical intensive care unit, or the neuroscience intensive care unit (NSICU) were analyzed. Kaplan-Meier curves were generated to determine time to death.
RESULTS: A total of 622 subjects were identified; 39.5% died in the emergency department, 10.6% went directly to the OR, 13.6% were admitted to the surgical intensive care unit, and 29.7% admitted to the NSICU. Of these subjects, 201 (32.2%) patients received blood within the first 4 h. By 24 h, early blood transfusion was associated with more rapid death for patients who were admitted to the NSICU (80% versus 60% mortality, P = 0.01) but not for patients taken directly to the OR (80% versus 70% mortality, P = 0.2). Admission coagulopathy by international normalized ratio (P < 0.01), but not anemia (P = 0.64) or acidosis (P = 0.45), correlated with a shorter time to death. In contrast, laboratory values obtained at 4 h after admission did not correlate with time to death.
CONCLUSIONS: Our data demonstrate that admission coagulation derangement and need for early blood product transfusion are the two factors most associated with early death after injury, particularly in those patients with traumatic brain injury. These data will help construct future models for futility of continued care in patients with trauma.
BACKGROUND: Historically, it has been assumed that the Emergency Department (ED) is a place for maximally aggressive care and that Emergency Medicine Providers (EMPs) are biased towards life-prolonging care. However, emphasis on early recognition of code status preferences is increasingly making the ED a venue for code status discussions (CSDs). In 2018, our hospital implemented a policy requiring EMPs to place a code status order (CSO) for all patients admitted through the ED. We hypothesized that if EMPs enter CSDs with a bias toward life-prolonging care, or if the venue of the ED biases CSDs towards life-prolonging care, then we would observe a decrease in the percentage of patients selecting DNR status following our institution's aforementioned CSO mandate.
METHODS: We present a retrospective analysis of rates of DNR orders placed for patients admitted through our ED comparing six-month periods before and after the implementation of the above policy.
RESULTS: Using quality improvement data, we identified patients admitted through the ED during pre (n=7,858) and post (n=8,069) study periods. We observed the following: after implementation DNR preference identified prior to hospital admission from the ED increased from 0.4% to 5.3% (relative risk (RR) 12.5; 95% CI: 5.2-29.9), defining CS in the ED setting at the time of admission increased from 2.4% to 98.6% (p <0.001), and DNR orders placed during inpatient admission was unchanged (RR=0.97 (95% CI = 0.88-1.07)).
DISCUSSION: Our results suggest that the ED can be an appropriate venue for CSDs.
During the novel coronavirus disease 2019 (COVID-19) pandemic, it is particularly critical to ensure that life-sustaining treatment (LST) such as intubation and resource-intensive cardiopulmonary resuscitation (CPR) are aligned with a patient’s goals and values, and to avoid LSTs in patients with a poor prognosis that are unlikely to be beneficial, but have a high risk of causing additional suffering. The high volume and acuity of COVID-19 patients makes it extremely challenging for emergency department (ED) clinicians to take adequate time to clarify goals of care (GOC). We implemented an ED-based COVID-19 palliative care response team focused on providing high-quality GOC conversations in time-critical situations. We examined the clinical characteristics and outcomes of patients who received this intervention.
Methods: This retrospective observational study was conducted in the ED of an urban, quaternary care academic medical center in New York, New York. We included 110 patients for whom the palliative care team was consulted between March 27, 2020, and April 10, 2020, with follow-up through May 9, 2020. Columbia University institutional review board approved this study and waived the need for informed consent.
Emergency department clinicians consulted the palliative care team for assistance with any palliative care-related needs, including GOC clarification and cases where stated GOC did not align with expected prognosis. The palliative care team (1 attending physician who was board-certified in hospice and palliative medicine, 1 hospice/palliative medicine fellow clinician, and 4 psychiatry resident physicians and fellow clinicians, all trained in GOC conversations and supervised by the palliative care attending physician) was available in person 12 hours per day, and for phone consultation overnight and on weekends. The palliative care intervention focused on GOC conversations: conveying the prognosis in a clear and simple way, exploring patients’ goals and values, and making care recommendations based on elicited goals.1,2
Deidentified demographic data were collected from the medical record. Primary outcomes included GOC before and after palliative care intervention, as well as GOC on death or discharge. Secondary outcomes included clinical course and length of stay in the hospital
Goals of care were defined as “full code” (pursue all LSTs including intubation and CPR); “do-not-resuscitate (DNR) only” (pursue all LSTs excluding CPR); “DNR/do-not-intubate (DNI), continue medical treatment” (pursue all LSTs excluding intubation and CPR); and “comfort-directed care” (forgo LSTs, deliver symptom-focused treatment only). The GOC were presumed to be full code if no advance directives or medical orders for life-sustaining treatment (MOLST) were found on presentation to the ED.
Six patients were still hospitalized at the time of data review; they were excluded from the analysis for clinical course.
Results: The 110 patients were aged a median (range) of 81.5 (46-101) years and 61 (55.4%) were women. Patient demographic and clinical characteristics are reported in Table 1. Most patients were community-dwelling elderly persons (aged >75 years) with at least 2 comorbidities and lacked decision-making capacity at the time of presentation. Very few patients presented with documented advance directives or MOLST and therefore were presumed to be full code.
The primary outcomes are summarized in Table 2. After initial palliative care intervention, the number of full code decreased from 91 patients (82.7%) to 20 patients (18.2%). Among these 71 patients (64.5%) in whom CPR was declined, mechanical ventilation was also declined in 61 patients (55.5%) (ie, 32 patients in DNR/DNI, continue medical treatment, 29 patients in comfort-directed care). On discharge, the number of full code further decreased to 9 patients (8.6%), whereas comfort-directed care increased to 54 patients (51.9%). The median (range) length of stay was 4 (0-28) days and 71 patients (68.2%) died in the hospital. Among 33 patients (31.7%) who were discharged alive, 6 patients (5.8%) were discharged with hospice care.
Discussion: The included patients’ demographic characteristics were consistent with those of critically ill patients with COVID-19 previously reported and with those of patients reported to be at highest risk of death from COVID-19. Patients without advance care planning conversations are known to be at risk of receiving unwanted, high-intensity, lower-quality care,5 even though many seriously ill patients do not prefer LSTs at the end of life.6
The most important finding in this study was, after palliative care intervention in the ED, most patients and their surrogates opted to forgo mechanical ventilation and/or CPR, and that tendency further increased on discharge. We believe timely GOC conversations by the palliative care team helped avoid unwanted LSTs for patients with a poor prognosis. Study limitations include potentially limited generalizability given the retrospective design at a single institution. Also, palliative care consultation was initiated by ED clinicians, which may have led to selection bias, though a high rate of altered GOC after intervention suggests significant, unaddressed need in the outlying population.
Background: The association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan.
Methods: A matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan–Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation.
Results: The mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group.
Conclusion: Among patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.
Background: Advance care planning (ACP) conversations are an important intervention to provide care consistent with patient goals near the end of life. The emergency department (ED) could serve as an important time and location for these conversations.
Objectives: To determine the feasibility of an ED-based, brief negotiated interview (BNI) to stimulate ACP conversations among seriously ill older adults.
Methods: We conducted a pre/postintervention study in the ED of an urban, tertiary care, academic medical center. From November 2017 to May 2019, we prospectively enrolled adults =65 years of age with serious illness. Trained clinicians conducted the intervention. We measured patients' ACP engagement at baseline and follow-up (3 ± 1 weeks) and reviewed electronic medical record documentation of ACP (e.g., medical order for life-sustaining treatment [MOLST]).
Results: We enrolled 51 patients (mean age = 71; SD 12), 41% were female, and 51% of patients had metastatic cancer. Median duration of the intervention was 11.8 minutes; few (6%) of the interventions were interrupted. We completed follow-up for 61% of participants. Patients' self-reported ACP engagement increased from 3.0 to 3.7 out of 5 after the intervention (p < 0.01). Electronic documentation of health care proxy forms increased (75%–94%, n = 48) as did MOLST (0%–19%, n = 48) during the six months after the ED visit.
Conclusion: A novel, ED-based, BNI intervention to stimulate ACP conversations for seriously ill older adults is feasible and may improve ACP engagement and documentation.
Background: Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature.
Study objective: We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France.
Method: In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process.
Results: There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives.
Conclusion: The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.
Background: Many patients with advanced cancer diagnosed following emergency presentation will likely benefit from palliative care (PC) interventions. This study assessed the potential patient-related barriers to
inpatient PC consultation among patients who were newly diagnosed with cancer after emergency admission (EA) and received only supportive care.
Methods: This observational study retrospectively obtained data on all patients who were admitted to our hospital after emergency transfer between January 2012 and November 2016. We identified patients for
whom cancer was listed as the primary disease in the post-hospitalization discharge summary. Out of these patients, we selected those with newly diagnosed cancer and determined whether they were referred for
inpatient PC consultation.
Results: This study recruited 141 patients with newly diagnosed cancer after EA (1.2% of all emergency transfer cases). Following diagnosis, the PC team intervened in 29.8% of all the patients enrolled in this
study and in 53.3% of patients who received only supportive care. In patients who received only supportive care, the patients who were not referred for PC consultation were significantly more likely to have shorter
survival time and less likely to receive disclosure about their cancer diagnosis than patients who were referred.
Conclusions: According to this study, short survival time and no disclosure of cancer diagnosis are potential patient-related barriers to inpatient PC consultation among patients with newly diagnosed cancer after EA.
Background: Our objectives were to test whether during a potentially life-threatening medical emergency, perceived threat (a patient’s sense of life endangerment) in the emergency department (ED) is common and associated with the subsequent development of posttraumatic stress disorder (PTSD) symptoms.
Methods: This study was an ED-based prospective cohort study in an academic hospital. We included adult patients requiring acute intervention in the ED for resuscitation of a potentially life-threatening medical emergency, defined as respiratory or cardiovascular instability. We measured patient-perceived threat in the ED using a validated patient self-assessment measure (score range = 0 to 21, with higher scores indicating greater perceived threat). We performed blinded assessment of PTSD symptoms 30 days after discharge using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5).
Results: Ninety-nine of 113 (88%) patients completed follow-up, with 98% reporting some degree of perceived threat, median (interquartile range [IQR]) perceived threat score 12 (6 to 17), and 72% reported PTSD symptoms in relation to their ED visit (median [IQR] PC-5 score = 7 [0 to 30]). Patients with respiratory instability had higher median (IQR) perceived threat scores (16 [9 to 18] vs. 9 [6 to 14)] and PCL-5 scores (10 [2 to 40] vs. 3 [0 to 17]) compared to patients without respiratory instability. In a multivariable linear regression model adjusting for potential confounders, greater perceived threat in the ED was independently associated with higher PCL-5 scores (ß = 0.79, 95% confidence interval [CI] = 0.15 to 1.42). Among the individual perceived threat items, the feeling of helplessness during resuscitation had the strongest association with PCL-5 score (ß = 5.24, 95% CI = 2.29 to 8.18).
Conclusions: Perceived threat during potentially life-threatening emergencies is common and independently associated with development of PTSD symptoms. Additional research to test whether reduction of perceived threat in the ED attenuates the development of PTSD symptoms following potentially life-threatening emergencies is warranted.
The emergency department (ED) provides immediate access to medical care for patients and families in times of need. Increasingly, older patients with serious illness seek care in the ED, hoping for relief from symptoms and suffering associated with advanced disease. Until recently, emergency medicine (EM) clinicians have been ill-equipped to meet the needs of patients with serious illness, and palliative services have been largely unavailable in the ED. However, in the past decade, there has been growing recognition from within both the EM and palliative medicine communities on the importance of palliative care provision in the ED. The past 10 years have seen a surge in EM-palliative care training and education, quality improvement projects, and research. As a result, the practice paradigm within EM for the seriously ill has begun to shift to incorporate more palliative care practices. Despite this progress, substantial work has yet to be done in terms of identifying ED patients in need of palliative care, training EM clinicians to provide high-quality primary palliative care, creating pathways for ED referral to palliative care and hospice, and researching the outcomes and impact of palliative care provision on patients with serious illness in the ED.
Introduction: The aim of this study was to investigate the current status of bereavement follow-up in Japanese emergency departments.
Methods: This study employed a cross-sectional design and conducted a nationwide survey of all emergency departments in Japan. Self-reported questionnaires were sent to the nurse leaders of each emergency department.
Results: of 289 nurse leaders approached, 145 (50.2%) responded. Only 17.9% emergency departments provided bereavement follow-up strategies, and the most frequent strategy was referral to a specialist for psychological treatment. Most nurse leaders perceived that bereavement follow-up is necessary, and the greatest need of the bereaved as perceived by the nurse leaders was explanation of the patient’s death. However, 60% of the nurse leaders perceived bereavement follow-up to be necessary but difficult, and the major challenges in bereavement follow-up were lack of time, knowledge, and skill.
Conclusion: in contemporary Japan, the prevalence of bereavement follow-up strategies offered by emergency departments was low, and although most nurse leaders perceived follow-up as necessary, it could not be provided because of limitations in human resources and staff training.
BACKGROUND: Patients at their end-of-life (EOL) phase frequently visit the emergency department (ED) due to their symptoms, yet the environment and physicians in ED are not traditionally equipped or trained to provide palliative care. This multicentre study aims to measure the current quality of EOL care in ED to identify gaps, formulate improvements and implement the improved EOL care protocol. We shall also evaluate healthcare resource utilisation and its associated costs.
METHODS AND ANALYSIS: This study employs a quasiexperimental interrupted time series design using both qualitative and quantitative methods, involving the EDs of three tertiary hospitals in Singapore, over a period of 3 years. There are five phases in this study: (1) retrospective chart reviews of patients who died within 5 days of ED attendance; (2) pilot phase to validate the CODE questionnaire in the local context; (3) preimplementation phase; (4) focus group discussions (FGDs); and (5) postimplementation phase. In the prospective cohort, patients who are actively dying or have high likelihood of mortality this admission, and whose goal of care is palliation, will be eligible for inclusion. At least 140 patients will be recruited for each preimplementation and postimplementation phase. There will be face-to-face interviews with patients' family members, review of medical records and self-administered staff survey to evaluate existing knowledge and confidence. The FGDs will involve hospital and community healthcare providers. Data obtained from the retrospective cohort, preimplementation phase and FGDs will be used to guide prospective improvement and protocol changes. Patient, family and staff relevant outcomes from these changes will be measured using time series regression.
ETHICS AND DISSEMINATION: The study protocol has been reviewed and ethics approval obtained from the National Healthcare Group Domain Specific Review Board, Singapore. The results from this study will be actively disseminated through manuscript publications and conference presentations.
Coronavirus-19 disease (COVID-19) has quickly spread to cause a global pandemic, and produces a spectrum of disease from mild respiratory illness to severe acute respiratory distress syndrome. Current estimates indicate that 15% of patients with COVID-19 will develop severe disease, and 5 to 10% will require intensive care-level support. In certain scenarios, escalation of life-sustaining therapies (defined as intubation, mechanical ventilation,vasopressor support, and/or hemodialysis) will either not be within the patient’s goals of care, or will unfortunately be unsuccessful. Overall mortality risk from COVID-19is estimated to be between 3 and 5%.
BACKGROUND: Little is known about the characteristics of patients needing palliative care consultation in the ED. This study aimed to investigate the impacts of initiating screening in acute critically ill patients needing palliative care on mortality, healthcare resources, and end-of-life care (EOL) in the intensive care unit in ED (EICU).
METHODS: We conducted an analysis study in Taipei Veterans General Hospital. From February 1 to July 31, 2018, acute critically ill patients in EICU were recruited. The primary outcomes were inhospital mortality and EOL care. The secondary outcomes included clinical characteristics and healthcare utilization.
RESULTS: A total of 796 patients were screened, with 396 eligible and 400 non-eligible patients needing palliative care consultations. The mean age was 74.8 ± 17.1 years, and 62.6% of the patients were male. According to logistic regression analysis, clinical predictors, including age (adjusted odds ratio [AOR], 1.028; 95% confidence interval [CI], 1.015-1.042), respiratory distress and/or respiratory failure (AOR, 2.670; 95% CI, 1.829-3.897), the Acute Physiology and Chronic Health Evaluation II score (AOR, 1.036; 95% CI, 1.009-1.064), Charlson Comorbidity Index score (AOR, 1.212; 95% CI, 1.125-1.306), and Glasgow Coma Scale (AOR, 0.843; 95% CI, 0.802-0.885), were statistically more significant in eligible patients than in non-eligible patients. The inhospital mortality rate was significantly higher in eligible patients than that in non-eligible patients (40.7% vs. 11.5%, p < 0.01). Eligible patients have a higher ratio in both vasopressor and narcotic use and withdrawal of endotracheal tube than non-eligible patients (p < 0.05).
CONCLUSION: Our study results demonstrated that initiating palliative consultation for acute critically ill patients in ED had an impact on the utilization of healthcare resources and quality of EOL care. Further assessments of the viewpoints of ED patients and their family regarding palliative care consultations and hospice care are required.
AIM: This project has two aims: 1) What do relatives to brought in dead describe as helpful and supportive care when they arrive at the emergency department to see and say goodbye to a deceased? 2) What do nurses describe as good nursing practice for brought in dead persons and their relatives and what may hinder or facilitate this practice in an emergency setting?.
DESIGN: A qualitative study within the methodology Interpretive Description.
METHODS: Data will be collected through three data sources: Individual interviews with relatives to brought in dead persons, participant observations of relatives to brought in dead persons during their presence in the emergency department and focus group interviews with emergency nurses.
DISCUSSION: Brought in dead persons and their relatives are received and cared for in emergency departments by emergency nurses. Knowledge of how to render care for the relatives to brought in dead persons in an acute setting including what skills and competences this require of the nurses is warranted. We need to explore, describe and comprehend the experiences of both the relatives and the nurses in order to point out potential areas of improvement.
IMPACT: This paper is a protocol of an Interpretive Description study offering insight into considerations and reflections in designing the study.
INTRODUCTION: Across the developed world, there are concerns about 'inappropriate' use of the emergency department (ED). Patients with palliative care needs frequently attend the ED. Previous studies define the 'reason' for presentation as the 'presenting symptom', which ignores the perspectives of service users. This paper addresses an acknowledged gap in the literature, which fails to examine the decision-making process that brings patients to the ED.
METHODS: In-depth narrative interviews were conducted with 7 patients (known to a specialist palliative care service and presenting to the ED during a 10-week period) and 2 informal caregivers. Analysis drew on 'Burden of Treatment Theory' to examine the meaning attributed by participants to their experience of serious acute illness, their capacity for action and the work required to access emergency care.
RESULTS: 5 themes were identified about how and why emergency services were accessed: capacity for action, making sense of local services, making decisions to access emergency services, experience of emergency care and coping with change. All narratives captured concerns surrounding the complexity of services. Participants struggled to piece together the jigsaw of services, and were subsequently more likely to attend the ED. Differences between the ways that patients with chronic obstructive pulmonary disease and cancer accessed the ED were prominent.
CONCLUSIONS: Further work is needed to understand and respond to decisions leading patients with palliative care needs to the ED, particularly in the context of locally fragmented services, poor signposting and confusion about available healthcare. The perspectives of service users are essential in shaping emergency care.
OBJECTIVES: To describe the clinical management of palliative sedation and the characteristics of sedated patients in 11 Catalan hospital emergency departments.
MATERIAL AND METHODS: Prospective descriptive study of a cohort of patients given palliative sedation between April and July 2018. We registered patient demographic and disease data, the Charlson comorbidity index (CCI), patient's point of origin before emergency department arrival, times related to emergency care, and medications used.
RESULTS: We included 323 patients (48.9% men) with a mean (SD) age of 84 (12) years. The CCIs were significantly higher in patients attended in level-I hospitals. Palliative sedation was the first option in 27% and was initiated within 18 (28) hours of arrival on average, an interval that was significantly shorter in level-II hospitals. Most patients (74.2%) died in the emergency department.
CONCLUSION: Patients treated with palliative sedation in hospital emergency departments are older and have serious concomitant conditions. Most patients are first treated with intention to cure. Time until the start of palliative sedation differs significantly according to hospital level.
BACKGROUND: Admission to the emergency department (ED) of patients with advanced or end-of-life (EoL) cancer saturates the services that provide active medical attention to the complications of anticancer therapy, and the lack of specific protocol limits proper handling.
OBJECTIVE: The aim of this study was to describe the characteristics of patients with advanced cancer admitted to the ED at the EoL in a comprehensive cancer center in Mexico.
PATIENTS AND METHODS: We conducted a retrospective analysis of patients admitted to ED of the National Cancer Institute of Mexico City, with 3 or less days before they died, between January 2011 and December 2018. The data collected included clinical and demographic characteristics, reason for admission to the ED, number of admissions to ED in the last month of life, and cancer treatment received.
RESULTS: A total of 426 patients were included; 60.8% were female with a median age of 60 years; 71.6% patients were receiving some kind of disease-modifying treatment, although the oncologist had considered they could die within 6 months, and 16 of them were receiving concomitant PC. 8.9% of these patients had been admitted 3 or more times to the ED in the last month. The principal reasons for admission to ED were dyspnea, uncontrolled pain, 12 patients were admitted in active death and 94 died within hours of admission to ED.
CONCLUSIONS: Palliative care approach in oncological patients admitted to ED is important to avoid unnecesary suffering at the EoL.
INTRODUCTION: With an increase in the population living with terminal illness, many patients are accessing EDs during the last days of their life. Yet EDs are often not well prepared to provide end-of-life (EOL) care. The aim of this review was to identify and synthesise studies that describe the views and experiences of emergency nurses in providing EOL care so as to understand the barriers and challenges that they face while caring for these patients and to identify factors that can support appropriate care delivery.
METHOD: A qualitative meta-synthesis was undertaken using a thematic approach. Study quality was assessed using the Joanna Briggs Institute Qualitative Assessment and Review Instrument tool. Five databases were searched in June 2016.
RESULTS: Eleven qualitative studies met the inclusion criteria and were assessed as having high quality. Sixty-nine findings were identified, combined into 11 descriptive themes and then synthesised into 3 analytical themes: (1) Incongruent ED environment and EOL care. (2) Lack of resources, systems and capacity. (3) EOL care as a rewarding act or an emotional burden.
CONCLUSION: The review identified a need for: (1) Additional training for nurses. (2) The development of clear guidelines in the form of pathways and protocols. (3) Having a separate space for the dying. (4) Providing a supportive environment for staff dealing with high emotional burden and challenging workloads. In order to improve EOL care, organisations must work on the barriers that hinder care provision.