The epidemiology of dying within 48 hours of presentation to emergency departments: a retrospective cohort study of older people across Australia and New Zealand.

BACKGROUND: Emergency department (ED) clinicians are more frequently providing care, including end-of-life care, to older people. OBJECTIVES: To estimate the need for ED end-of-life care for people aged ≥65 years, describe characteristics of those dying within 48 hours of ED presentation and compare those dying in ED with those dying elsewhere. METHODS: We conducted a retrospective cohort study analysing data from 177 hospitals in Australia and New Zealand. Data on older people presenting to ED from January to December 2018, and those who died within 48 hours of ED presentation, were analysed using simple descriptive statistics and univariate logistic regression. RESULTS: From participating hospitals in Australia or New Zealand, 10,921 deaths in older people occurred. The 48-hour mortality rate was 6.43 per 1,000 ED presentations (95% confidence interval: 6.31-6.56). Just over a quarter (n = 3,067, 28.1%) died in ED. About one-quarter of the cohort (n = 2,887, 26.4%) was triaged into less urgent triage categories. Factors with an increased risk of dying in ED included age 65-74 years, ambulance arrival, most urgent triage categories, principal diagnosis of circulatory system disorder, and not identifying as an Aboriginal or Torres Strait Islander person. Of the 7,677 older people admitted, half (n = 3,836, 50.0%) had an encounter for palliative care prior to, or during, this presentation. CONCLUSIONS: Our findings provide insight into the challenges of recognising the dying older patient and differentiating those appropriate for end-of-life care. We support recommendations for national advanced care planning registers and suggest a review of triage systems with an older person-focused lens.

End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland.

OBJECTIVE: To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. METHODS: An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. RESULTS: The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. CONCLUSIONS: The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.

Providing end of life care in the emergency department: A hermeneutic phenomenological study.

BACKGROUND: Registered nurses report the experience of delivering end of life care in emergency departments as challenging. The study aim was to understand what it is like to be a registered nurse providing end of life care to an older person in the emergency department. METHODS: A hermeneutic phenomenological study was conducted in 2021, using semi-structured interviews with seven registered nurses across two hospital emergency departments in Queensland, Australia. Thematic analysis of participants' narratives was undertaken. FINDINGS: Seven registered nurses were interviewed; six of whom were women. Participant's experience working in the emergency department setting ranged from 2.5-20 years. Two themes were developed through analysis: (i) Presenting the patient as a dying person; and (ii) Mentalising death in the context of the emergency department. CONCLUSIONS: Nurses providing end of life care in the emergency department draw upon their personal and aesthetic knowing to present the dying patient as a person. The way death is mentalised suggests the need to develop empirical knowing about ageing and supportive medical care and ethical knowing to assist with the transition from resuscitation to end of life care. Shared clinical reflection on death in the emergency department, facilitated by experts in ageing and end of life care is recommended.

The role of law in end-of-life decision-making in emergency departments and intensive care units: a retrospective review of current practice in a Queensland health service.

Objective There is limited evidence about how legal frameworks that underpin end-of-life decisions are applied in practice. This study aimed to identify how end-of-life decisions are made and documented in emergency departments and intensive care units. The secondary aim was to explore the extent to which the legal processes featured in these decisions. Methods A retrospective chart audit of 85 adult patients who died in the emergency departments and intensive care units of a Queensland health service was undertaken. Quantitative data were analysed and reported using descriptive statistics. Qualitative textual data were analysed using inductive content analysis. Results Nearly all admissions were unplanned (97.6%), and most patients (74.1%) were admitted from home. Only one patient had an advance health directive, although all had an eligible substitute decision-maker. The qualitative analysis revealed two main concepts - 'healthcare professionals choreograph the end of life' and 'patients and families are carried on an unplanned journey'. Conclusions There was limited documentation related to the application of the legal framework in these decisions. Healthcare professionals relied on their clinical judgment about what was in the best interest of the patient. It was common for there to be a substantial effort to achieve consensus in decision-making which coincidently complied with the law.

End-of-life care: A retrospective cohort study of older people who died within 48 hours of presentation to the emergency department.

OBJECTIVES: To describe the characteristics of, and care provided to, older people who died within 48 h of ED presentation. METHODS: A descriptive retrospective cohort study of people 65 years and older presenting to two EDs in Queensland, Australia, between April 2018 and March 2019. Data from electronic medical records were collected and analysed. RESULTS: Two hundred and ninety-five older people who died within 48 h of ED presentation were included. Nearly all arrived by ambulance (92%, n = 272) and 36% (n = 106) were from aged care facilities. Three-quarters (75%, n = 222) were triaged into the most urgent triage categories (i.e. Australasian Triage Scale; ATS 1/2). Fewer than half were previously independent with mobility (38%, n = 111) and activities of daily living (43%, n = 128). Sixty-one per cent (n = 181) had a pre-existing healthcare directive. Twenty-two per cent (n = 66) died in ED, most commonly due to pneumonia, intracerebral haemorrhage, cardiac arrest and/or sepsis. Over half had one or more ED visits (52%, n = 154) and/or hospital admissions (52%, n = 152) 6 months prior. CONCLUSIONS: Identification of patients at end-of-life (EoL) is not always straightforward; consider recent reduction in independence and recent ED visits/hospital admissions. System-based strategies that span pre-hospital, ED and in-patient care are recommended to facilitate EoL pathway implementation and care continuity.

Emergency department and intensive care unit health professionals' knowledge and application of the law that applies to end-of-life decision-making for adults: A scoping review of the literature.

BACKGROUND: Laws that regulate healthcare practice at the end of life reflect the values of the society where they apply. Traditionally, healthcare professionals rely on their clinical knowledge to inform treatment decisions, but the extent to which the law also informs health professionals' decision-making at the end of life is uncertain. OBJECTIVE: The objective of this study was to describe what healthcare professionals working in emergency departments and intensive care units know about the law that relates to end-of-life decision-making for hospitalised adults and what affects its application. REVIEW METHOD: This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. DATA SOURCES: Data were sourced by searching the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL [via EBSCOhost]), Nursing and Allied Health and Health and Medical Collection (via ProQuest Central), Excerpta Medica dataBASE (Embase), PubMed, PsycINFO, and HeinOnline. RESULTS: Systematic screening of the search results and application of inclusion criteria resulted in the identification of 18 quantitative and three qualitative articles that were reviewed, summarised, and reported. Ten of the quantitative studies assessed knowledge and attitudes to law or end-of-life decision-making using hypothetical scenarios or vignettes. Qualitative studies focussed on how the law was applied when end-of-life decisions were made. End-of-life decision-making is mostly based on the clinical needs of the patient, with the law having a secondary role. CONCLUSION: Around the world, there are significant gaps in healthcare professionals' legal knowledge. Clinical factors are considered more important to end-of-life decision-making than legal factors. End-of-life decision-making is perceived to carry legal risk, and this results in the provision of nonbeneficial end-of-life care. Further qualitative research is needed to ascertain the clinician-related factors that affect the integration of law with end-of-life decision-making.

The Australasian Resuscitation In Sepsis Evaluation: Fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand.

OBJECTIVES: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. METHODS: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. RESULTS: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87-100). Median time to first intravenous antimicrobials was 77 min (42-148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500-3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000-5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4-8.5%). CONCLUSION: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy.

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan.

OBJECTIVE: There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). METHODS: ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in-hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. DISCUSSION: This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.