Difficulty of the decision‐making process in emergency departments for end‐of‐life patients

Abstract

Background In emergency departments, for some patients, death is preceded by a decision of withholding or withdrawing life‐sustaining treatments. This concerns mainly patients over 80, with many comorbidities. The decision‐making process of these decisions in emergency departments has not been extensively studied, especially for noncommunicating patients. Aim The purpose of this study is to describe the decision‐making process of withholding and withdrawing life‐sustaining treatments in emergency departments for noncommunicating patients and the outcome of said patients. Design We conducted a prospective multicenter study in three emergency departments of university hospitals from September 2015 to January 2017. Results We included 109 patients in the study. Fifty‐eight (53.2%) patients were coming from nursing homes and 52 (47.7%) patients had dementia. Decisions of withholding life‐sustaining treatment concerned 93 patients (85.3%) and were more frequent when a surrogate decision maker was present 61 (65.6%) versus seven (43.8%) patients. The most relevant factors that lead to these decisions were previous functional limitation (71.6%) and age (69.7%). Decision was taken by two physicians for 80 patients (73.4%). The nursing staff and general practitioner were, respectively, involved in 31 (28.4%) and two (1.8%) patients. A majority of the patients had no advance directives (89.9%), and the relatives were implicated in the decision‐making process for 96 patients (88.1%). Death in emergency departments occurred for 47 patients (43.1%), and after 21 days, 84 patients (77.1 %) died. Conclusion There is little anticipation in end‐of‐life decisions. Discussion with patients concerning their end‐of‐life wishes and the writing of advance directives, especially for patients with chronic diseases, must be encouraged early.

Death and do-not-resuscitate order in the emergency department: A three-year retrospective study in the Chinese mainland

“…Because of the lack of ADs, family members need to express patients' wishes concerning their end-of-life preferences. [31] Kwok et al [32] found that most family surrogates had poor knowledge of lifesustaining treatments, and most of them depended on their views but not the patients' wishes to make the fi nal DNR directives. By tradition, the eldest son or daughter is obliged by fi lial piety to do everything to prolong the elderly patient's life; the opinions of family members and health-care professionals take precedence over personal opinions or preferences.…”

Poor Involvement of General Practitioners in Decisions of Withholding or Withdrawing Life-Sustaining Treatment in Emergency Departments

“…Indeed, most patients didn't have advance directives before admission in the ED. 15 It could help to avoid sending them to the ED. It has been found that the main perceived barriers of GP-patient communication in palliative care are the lack of availability of GPs and also GPs' ambivalence to discuss 'bad prognosis.…”

Interactions between persons—Knowledge, decision making, and the co‐production of practice

“…End‐of‐life decisions present another area where the meaningful application of person‐centred approaches and SDM seems at once eminently important and particularly difficult to implement. Marion Douplat et al conducted a prospective multicentre study in three emergency departments of university hospitals in France, to describe the management of the decision‐making process of withholding and withdrawing life‐sustaining treatments. The results made it clear that there is still very little anticipation in end‐of‐life decisions, and the authors conclude that “discussion with patients concerning their end‐of‐life wishes as well as the writing of advance directives, especially for patients with chronic diseases, must be encouraged early.”…”

“…It includes papers on the nature of reasoning and evidence, the on‐going problems of how to “integrate” different forms of scientific knowledge with each other, and with broader, humanistic understandings of reasoning and judgement, patient and community perspectives . Discussions of the epistemological contribution of patient perspectives to the nature of care, and the crucial and still under‐developed role of phenomenology in medical epistemology, are followed by a broad range of papers focussing on SDM, analysing its proper meaning, its role in policy, methods for realizing it and its limitations in real‐world contexts …”