In a new study, deaths in U.S. emergency departments were estimated to account for 11.3% of total deaths from 2010 to 2019.
Death during or shortly after an emergency department visit is relatively common, and EDs should be prepared to provide better end-of-life care, according to a new research article.
From a patient experience point of view, it is unlikely that most EDs are a good setting for an unanticipated death. Earlier research on patients with cancer who die in an ICU shows there is a lower quality experience such as physical distress than patients who die at home.
The new research article, which was published by JAMA Network Open, features information drawn from the Optum clinical electronic health record data set from 2010 to 2020. Data was also used from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and U.S. Census.
The study features several key data points:
- Among more than 104 million patients with more than 96 million ED visits, 205,372 ED deaths were found in the Optum data set, with a median age of 72
- Deaths in EDs were estimated to account for 11.3% of total deaths from 2010 to 2019
- A third of people who died nationally visited an ED within one month of their death
- The proportion of deaths occurring in the ED decreased 0.27% annually but the proportion of people who died within one month of an ED visit increased by 1.2% annually
- Compared to all ED visits, patients with ED visits resulting in death were older, male, and had higher Charlson Comorbidity Index scores
- Among patients older than 80 who had ED visits, nearly 1 in 12 died within one month
"This retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently," the study's co-authors wrote.
Interpreting the data
The data suggest approaches to end-of-life care in the ED setting, the study's co-authors wrote. "We found that more than 1 in 3 U.S. residents come to the ED within 1 month of their death, a proportion that has increased 42% over a decade. Moreover, nearly 300,000 U.S. residents die in the ED annually. Taken together, these findings highlight a pressing need to develop systems and resources to support end-of-life care in the ED. Unsurprisingly, we find that patients with death proximate to their final ED encounter are older and have significantly more comorbidities compared with the overall ED population. … These patients may exhibit identifiable trajectories of dying that offer an opportunity to avoid unwanted aggressive care or hospitalization at end of life."
The quality of end-of-life care in the ED is generally suboptimal, the study's co-authors wrote. "There is general consensus that delivering high-quality end-of-life care in the ED is an unmet need. Compared with dying at home or in a hospice facility, quality of dying in the hospital is worse and may lead to protracted grief and psychological distress for families. Time constraints, patient volume, and environmental factors may contribute to suboptimal patient care and family experience."
The study's co-authors offer suggestions for improving end-of-life care in EDs. "Development and implementation of policies, structural changes, and allocation of additional resources can improve delivery of care to these patients. ED programs should clearly include grief and bereavement resources. Practitioners and staff in the ED should have core primary palliative care skills, including symptom management for actively dying patients, the ability to give serious news, and focus on talking to patients and families about goals of care."
EDs should be prepared to connect patients near the end of life with palliative care and hospice care, the study's co-authors wrote. "ED practitioners and systems of care should consider developing relations with community palliative care and hospice programs to follow up with the large number of patients who, although they will survive their acute encounter, have impending or ongoing palliative care needs."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The quality of end-of-life care in emergency departments is generally suboptimal, researchers say.
Measures to improve end-of-life care in emergency departments include offering grief and bereavement resources as well as training staff to have core palliative care skills.