A Systematic Approach to Comfort Care Transitions in the Emergency Department.

BACKGROUND: Approximately 25-30% of Americans die within hospitals. An increasingly geriatric and chronically ill population arrive at emergency departments (EDs) for their terminal presentation. Many patients will not choose, nor are EDs obligated to deliver, futile care. Instead, aggressive comfort care may alleviate patient, family, and clinician distress.

OBJECTIVES: To discuss best practice through a systematic approach to comfort care transitions for the dying ED patient.

METHODS: Authors utilized a structured literature search conducted via PubMed (MEDLINE), Embase, and CINAHL databases, including studies from 1998 onward focusing on symptom palliation and coordination of care for acutely dying patients.

DISCUSSION: Comfort care begins with the language used to introduce the transition. Frame choices to avoid creating feelings of familial abandonment. Prognostication in the dying process helps guide treatment planning and stewarding families. Symptom management in the actively dying patient involves diligent titration of medications as well as thoughtful ordering in de-escalation of life-support modalities. Compassionate extubation necessitates anticipation of postextubation dyspnea or airway loss, and therefore may require step-wise weaning of pulmonary support. Suffering at the end of life for patients and families is multidimensional, and is best approached with an interdisciplinary effort involving clinicians, social work, and chaplaincy.

CONCLUSION: Comfort care deaths are a daily occurrence in the ED. A systematic approach to these transitions ensures optimal care for patients in their final hours and families' experience of these events.