Mortality As A Choice? Untold Stories From The Emergency Department
Aim. To explore the therapeutic approaches used for end-of-life (EOL) patients admitted to the emergency department (ED), and to examine whether the decision to perform extending life treatment (ELT) or allow natural death (AND) is dependent on medical staff characteristics and therapeutic field variables.
Methods. A retrospective archive study was conducted from January 2015 to December 2017 in the ED of a tertiary hospital. The study sample consisted of 644 EOL patients that died in the ED during the study period. For each patient, data was collected and measured of the dying process (ELT vs. AND), individual characteristics, morbidity and mortality variables, ED setting variables, and variables associated with the medical staff.
Results. Most of the patients experienced natural death (N=339, 53%), while 147 (23%) received ELT. Twenty-four percent (N=158) of patients were dead on arrival (DOA) after emergency medical services therapy. The main causes of mortality in the ED were terminal oncology (27%), severe sepsis (18%), and multi organ failure (17%). A positive association was found between age and the AND approach (t(483)=2.864, p=0.004(. Males tended to receive ELT more than females (p<.001). No correlations were found between staff shift, day and the type of dying process. There was a strong positive correlation between Arab nurses and the AND approach (p=.001). Jewish patients experienced AND at higher rates compared to Arab patients (54.3% vs. 44.3%, p=0.035). Logistic regression analysis indicated that more workload in the ED and the more severity of the triage classification predicted more ELT (OR=1.670, p=.003 and OR=1.423, p<.001, respectively).
Conclusions: The type of therapeutic approach used for EOL patients in the ED are dependent on variables in all three treatment layers; the patient, the medical staff and the ED setting. There is therefore a need for future interventions to ensure that no external factors influence the dying process decision.
