see also:

• NSW College of Emergency Nursing - End of Life guidelines (pdf)
• NSW Govt - End of Life Care and decision making guidelines

• end of life care is a critical aspect for an ED which must be approached with sensitivity, decisiveness and compassion.
• end of life care in this article refers more to the acute situation found in the ED where it is likely the patient will die within a matter of hours or days. See elsewhere for palliative care of patients with terminal illnesses requiring prolonged care such as provided by hospices.
• it is critical to understand that resuscitative procedures such as intubation should NOT be attempted if an ICU department would not consider such a patient for admission, irrespective of the wishes of the family - this would NOT be in the interest of the patient whose suffering would be prolonged, and they would almost certainly never regain consciousness post-extubation - thereby preventing family an opportunity to partake in a final parting while the patient can still communicate.
• when a potentially reversible problem is suspected, the ratio of the risk and discomfort of diagnostic and therapeutic interventions needs to be considered in light of the patients projected lifespan and probability of the therapy being successful.
• nursing home patients who are not applicable for intubation should have a standing NFR order.
• if they deteriorate with a condition that is obviously not easily reversible, then, ideally, they should receive their end of life care at the nursing home where they and their family are familiar with both environment and staff. To be transferred unnecessarily to an ED to die is an added stress to all concerned and usually fails both the patient and their family at this important time.
• please see the above documents for more details and legal aspects including patient rights to receive or refuse treatments, advanced directives, the doctor's right to with-hold or withdraw treatment which are not in the patient's interests, and the right to give pain killers and sedatives with the prime aim to reduce a patient's discomfort despite the knowledge that doing so may hasten an inevitable death.

• early decision, preferably by a senior doctor, that the current event will very likely be a terminal event and that resuscitative attempts would not be in the interests of the patient and would only prolong suffering before an inevitable death.
• early discussion with family, and patient if possible
• document Not For Resuscitation (NFR) order to ensure staff are empowered to provide the best end of life care possible
• aim to have patient transferred to an appropriate ward bed as soon as possible - the ED is NOT the place for planned births nor for end of life care - the patient and family deserves peace and quiet, and the environment and privacy to allow the final parting and grieving with dignity.
• ideally, the patient should be admitted to a palliative care bed or returned to the familiar environment of their nursing home, but if neither of these are possible, then a general medical ward admission is a reasonable compromise.
• patient and family should be offered access to a priest or similar spiritual leader, for last rites, etc.

• s/cutaneous line should be inserted and any iv line removed
• s/c fentanyl 25-50mcg prn for pain, agitation or dyspnoea
• s/c midazolam 2.5mg prn for agitation or dyspnoea
• s/c haloperidol 0.5mg prn for vomiting
• s/c normal saline at a rate of 1L/24hrs for comfort to avoid development of dehydration