End of life care in the Emergency Department

Why recognising dying matters

Recognising that someone may be approaching the end of their life can be difficult, particularly in the busy and sometimes unpredictable environment of the Emergency Department. We may meet people and families at a moment of profound distress, with little time to build a relationship or understand what matters most to them. It is understandable that these conversations feel daunting.

Yet recognising the possibility of dying creates an opportunity to offer the right care: to treat distress, consider reversible problems, explain uncertainty honestly and help patients and those close to them make informed choices. End of life care is not an alternative to good emergency medicine; it is part of it. Compassionate care remains active care.

Different trajectories, different degrees of uncertainty

ED clinicians are familiar with sudden deterioration and death. Many people, however, experience a longer course of cancer, organ failure, frailty or dementia.

In organ failure and frailty, periods of recovery may follow serious deterioration, making it difficult to know whether this episode will be the last.

The Chart from WHO illustrates these patterns and proportions in a typical UK GP list

It helps to distinguish two questions: might this person be in the final year of life, and might they be dying in the next hours or days? The Gold Standards Framework supports the first question; recognition of the last days requires repeated, individual clinical assessment. Neither can be answered by a score alone.

Recognising someone who may benefit from a palliative approach

The GSF Proactive Identification Guidance (7th edition, June 2022) suggests asking: “Would I be surprised if this person died in the next year, months, weeks or days?” Consider this alongside a decline in function, repeated unplanned admissions, increasing dependence, multimorbidity, weight loss, difficult symptoms and reduced response to treatment. These are prompts for assessment and conversation—not criteria for withholding active treatment.

Adapted and condensed from GSF Proactive Identification Guidance (June 2022). Indicators should be interpreted in context, with clinical judgement, patient wishes and potential reversibility.

These indicators are not validated ED prediction rules.
In particular, thresholds and mortality estimates quoted in the 2022 GSF document should not be used as stand-alone prognostic claims for an individual patient.

Condition	Indicators that should prompt consideration
Heart disease	NYHA III–IV heart failure with symptoms despite optimal treatment; repeated admissions (GSF cites 3 in 6 months); severe untreatable coronary/peripheral vascular disease; persistent symptoms, arrhythmias, declining renal function or other major comorbidity.
COPD / respiratory failure	Severe COPD (e.g. FEV₁ <30% predicted); distressing breathlessness despite optimal treatment; ≥3 COPD admissions in a year; long-term oxygen criteria; MRC breathlessness grade 4–5; prior NIV/critical care, cachexia or cor pulmonale.
Kidney disease	Progressive stage 4–5 CKD (eGFR <30 mL/min); >3 unplanned admissions/year; poorly tolerated dialysis or a decision for conservative kidney management; refractory symptoms, fluid overload or functional decline.
Liver disease	Advanced cirrhosis (consider Child–Turcotte–Pugh); hepatocellular carcinoma; limited transplant/treatment options; malnutrition, infection, raised INR or hyponatraemia.
Neurological disease	Progressive physical or cognitive decline despite therapy; inability to communicate needs; dysphagia with aspiration, repeated admissions without return to baseline; falls, dependence or complex uncontrolled symptoms.
Parkinson’s disease / MND	Parkinson’s: increasing “off” periods, less effective/complex medicines, dyskinesia and falls. MND: aspiration pneumonia, vital capacity <70% predicted or need for NIV.
Stroke	Persistent severe disability or paralysis, significant complications or lack of recovery; major cognitive impairment. Prognosis after acute stroke is uncertain and must be assessed individually.
Frailty, dementia and multimorbidity	Increasing dependency and recurrent crises; CFS ≥7; advanced dementia with loss of meaningful communication, aspiration, recurrent delirium, poor intake or weight loss; multiple conditions complicating day-to-day care.
Cancer	Metastatic or treatment-refractory disease with deteriorating function; spending >50% of time in bed; persistent symptoms despite optimal palliative oncology.

Communication and uncertainty: you are not alone

These conversations can be emotionally demanding for clinicians as well as patients and families. Seek support from nursing colleagues, senior ED clinicians, the admitting specialty and palliative care teams. Shared discussion often improves both decisions and confidence. Allow time and privacy wherever possible, use an interpreter when needed, and ask what the patient already understands and wants to know.

Clear, kind language is usually more helpful than euphemisms. For example: “I am worried that your mum is very unwell. Despite the treatment we are giving, there is a possibility she may die.” Pause, listen and allow questions. Avoid giving certainty where none exists.

When asked “How long?”, it is reasonable to say: “I wish I could give you an exact answer. It may be hours to days, but we cannot be sure. We will keep reviewing her and will tell you if our assessment changes.” If a time-limited trial of treatment is appropriate, explain what improvement would look like, when it will be reviewed and what happens if it does not help.

Decisions should reflect the person, not just the diagnosis

Ask about the person’s priorities, what they would find burdensome, and their preferred place of care where feasible.
Check existing advance care plans, ReSPECT documentation, any valid and applicable advance decision to refuse treatment, and health and welfare lasting power of attorney where relevant.
Presume decision-making capacity unless there is reason to assess it. If capacity is lacking for a specific decision, follow the Mental Capacity Act best-interests process and consult those close to the person as appropriate.
A DNACPR decision relates to CPR; it does not mean “do not treat”. Document proportionate treatments, escalation limits, review plans and the rationale separately.
Assess and treat reversible causes where doing so is clinically appropriate and consistent with the person’s goals. Seek senior advice when prognosis or treatment benefit is unclear.

Comfort, symptom relief and anticipatory medicines

Comfort is an active clinical priority. Attend to pain, breathlessness, anxiety, agitation, nausea, secretions and other distressing symptoms. Offer privacy, positioning, mouth and lip care, support for drinking where safe and desired, and spiritual or cultural support when welcomed. Discuss hydration and clinically assisted hydration individually, including potential benefits and burdens.

For a person likely to need symptom control in their final days, prescribe anticipatory medicines early using the appropriate local EPR order set, but tailor each prescription to the patient. Specify indication, dose, route and review arrangements; consider renal/hepatic impairment, prior opioid exposure, allergies and interactions. A prescription is not an instruction to administer every medicine: assess symptoms immediately before use, review response and adverse effects, and seek palliative/pharmacy advice if symptoms are difficult to control.

Before leaving the ED: a brief practical check

Is the patient comfortable now, and who will reassess symptoms?
Have we documented uncertainty, treatment goals, escalation decisions and the agreed review point?
Has the patient (where appropriate) and those important to them been given a clear explanation and an opportunity to ask questions?
Is there a named team taking responsibility and a safe handover, including medicines and any relevant community support?

Useful Links

References

Gold Standards Framework. Proactive Identification Guidance, 7th ed. June 2022.

NICE NG31. Care of dying adults in the last days of life. https://www.nice.org.uk/guidance/ng31

NICE NG142. End of life care for adults: service delivery. https://www.nice.org.uk/guidance/ng142

GMC. Treatment and care towards the end of life: good practice in decision making. https://www.gmc-uk.org/professional-standards/the-professional-standards/treatment-and-care-towards-the-end-of-life