Unexpected Patient Demise in the Emergency Department

Image Credit: Pixabay

Author: Victoria Weston, MD
2015-2016 RSA President
Originally published: Common Sense January/February 2016

I could hear the wails of grief coming from our trauma bay. It was the start of my shift, and the prior team had recently terminated an unsuccessful resuscitation. The patient had been chronically ill and had collapsed while checking in at our triage desk. Although the patient had cancer and had been unwell for years, his family was shocked and devastated by their sudden, unexpected loss.

Sometimes you see a patient come through the door and know things aren’t going to go well, whether it’s the obese tachypnic patient on full face mask gasping for air, the pale patient with an active GI bleed and reeking of melena, or the chest pain patient who is diaphoretic and ill-appearing. Other times, people come in with chronic illness but alert and looking well, only to die suddenly within a few hours of arrival.

There has been ample discussion over the past several years about dealing with unexpected death in the emergency department, and more recently when a photo of a grieving physician went viral earlier this year. We deal with unexpected illness and death on a daily basis — unlike many of our colleagues in other specialties, who practice in more controlled and predictable environments. Telling family members about an unexpected death or critical illness can be more deeply challenging than many of the other things we do.

I recently discussed this with a faculty member affiliated with my institution who has a wonderful bedside manner. She is pragmatic in her practice and honest with patients — when they are critically ill she tells patients they have a high chance of dying that day, and if they need to make any phone calls, now is the time. She is also honest with family members about the expected course. In her experience this has been successful, and although some of her patients have died in the ED, they had the opportunity to say goodbye to their loved ones and their loved ones had the chance to see them one last time and have closure as well.

When initially thinking about this approach, I envisioned myself in the patient’s shoes. I wondered how it would feel to face your own mortality, and be told that today would probably be your last day. Then I pictured a patient I saw recently. She was in her fifties, with weeks of worsening abdominal pain. The CT showed a pancreatic mass with widespread metastases. The patient and her daughter were some of the nicest people I’d cared for that day and I dreaded giving them what was, in my mind, a death sentence. As I told the patient and her family, her daughter sobbed but the patient was calm — she already knew.

Addressing code status and goals of care on a busy shift can be a challenge, but perhaps by being forthright about patients' anticipated clinical course, we can help provide closure for patients and their families, allow for proper goodbyes, and set the stage for a more peaceful death.