In every hospital that I know about that has an Emergency Department (ED), the vast majority of the deaths in the institution are either in the ED or in the ICU. Further, many of the people who die in the ICU come in through the ED on the verge of dying. They are sent to the ICU, not because their lives will be prolonged by aggressive care but because the ED staff, including the chaplain, is not trained or positioned to either recognize or deal appropriately with the fact that this patient is on a trajectory which is going to lead to their imminent death. Since the process is not set up to allow the patient to die in the ED and the patient needs aggressive care to stay alive even for a short period of time, the ICU is the only option. Thus, the dying patient spends the last moments of their life hooked up to lots of machines which may even be hastening their dying and in a lot more discomfort that necessary.
Now, Dr. Garrett Chan from the Emergency Department Clinical Decision Unit at Stanford Hospital has published a very helpful article that identifies seven trajectories of approaching death in the ED: 1. Dead on arrival; 2. Prehospital resuscitation with subsequent ED death; 3. Prehospital resuscitation with survival until admission; 4. Terminally ill and comes to the ED; 5. Frail and hovering near death; 6. Alive and interactive on arrival, but arrests in the ED; and 7. Potentially preventable death by omission or commission. His conclusion is that recognition of these trajectories will help clinicians to “be more astute in their recognition of the clinical situation and react appropriately, will help identify the transitions to the EOL phase, and will help to explore the possibilities open to the patient, family and clinicians.
While a good deal of the recognition of these trajectories relies on medical information, the chaplain, because he or she will not always be intensely involved with one or two patients, can have a perfect vantage point to observe one of these trajectories unfolding and help the staff and the family recognize the clinical reality and catalyze the appropriate discussion of goals of care.
Chan GK. (2011) Trajectories of Approaching Death in the Emergency Department: Clinician Narratives of Patient Transitions at the End of Life. J. of Pain and Symptom Management. 42(6), 864-881.