RCN Curriculum and Competency Framework for Emergency Nursing: CD2 2.2.8 & CD2 2.2.9.
When I disclose to new acquaintances that I’m an Emergency Care Nurse, conversation tends to drift toward the courageous, life-saving experiences they imagine I must partake in daily. These perceptions are swiftly corrected; I personally view my predominant role in A&E is to facilitate the best possible outcome for my patient, it’s incredibly important to recognise that some of these individuals will die – and that this isn’t always a failure on our part. In this blog we shall discuss some of the crucial aspects of the process to consider: consideration of death, breaking bad news, and care of the deceased.
Failure to Prepare…
With increasing numbers of patients – particularly the elderly – dying in hospital (1), it is incredibly important that sometimes, intimidating talks are had at the frontline, in the emergency department. Holding conversations at the bedside with our patients and their nearest-and-dearest, about their wishes, treatment preferences, resuscitation status and escalation of care is crucial in promoting dignity and autonomy through our care.
Many patients will already have had this conversation, and will express their wishes through documentation in the community – the often witnessed, “red form” to represent a DNACPR or other local paperwork to invoke an agreed limitation on the interventions applied in their care.
For example, 82yo David with COPD and congestive cardiac failure: may wish for medical management and ward level care to include non-invasive-ventilation – but intubation, ventilation and transfer to critical care may not be in his best interests.
Many hospitals and local trusts may hold their own “escalation of care” paperwork; it is important to familiarise yourself with this; it may be you initiating that conversation in A&E with the attending Doctor, “should we be talking about…?”(2). In some situations, it is important to acknowledge patient wishes but realise our own limitations; I’ve witnessed a number of scenarios where family members wish for “everything” to be done for their elderly relative, but as a team we’ve had to clinically reinforce and advocate to avoid a potentially futile and traumatic experience for our patient – e.g. CPR.
As nurses we must ensure appropriate documentation, openness with our patients and promote awareness through the multidisciplinary team. We are advocates for our patients, and often only have one chance to get this right!
Critical Conversations…
As many talks and preparations may be had to pre-empt and prepare for death, it may eventually take us by surprise, or arise in an unexpected fashion e.g., traumatic or accidental. Many A&E departments will have a room designated for private conversations with families and loved ones for such difficult conversations.
In my own practice; regardless of how senior a practitioner may be, they should not be venturing into a difficult conversation with family alone – a representative from the emergency or nursing team should always be present and engage with family.
A brief conversation on your part prior to meeting family may help prepare as to how the process should flow, any difficulties predicted or challenges in your approach. Some clinicians may use a tool in breaking bad news such as SPIKES (3).
Setting the scene: “Hello, my name is…”
Perception. “What do you know so far…?”
Inform. “…Unfortunately, David has died…”
Knowledge. “Do you have any questions…?”
Empathy. Express empathy and concern. Validation of grieving.
Summary/Strategy. “If you have any further questions… further information”
Regardless of template or protocol, it is important for us to take heed of, and invoke forms of non-verbal communication. Our posture, facial expressions and use of touch (4) are crucial in our demonstration of empathy and sensitivity.
Also important to acknowledge within these difficult conversations is that there may be somebody else within the hospital or community better equipped to support this family. Provision of spiritual or religious care is a crucial quality indicator in end of life care (5). Always remember to offer, and document the family or patient’s preference or wishes. Get to know your hospital chaplaincy team!
A brilliant podcast from SMACC (6) demonstrates difficult conversations in a critical care environment and observes the lessons learned through simulation. Does your local area present opportunities for training, discussion or debrief with regards to these conversations with families?
Final Moments of Care…
Provision of the last stages of care for a deceased patient in A&E is often undertaken by the attending Emergency Nurses (7).
Certification of death must be documented and a process undertaken by an attending Doctor. Not all deaths in A&E may be immediately certified; a procedural discussion with the local coroner’s office may be required to the circumstances surrounding the patient’s presentation. However, death may be confirmed by appropriately certified clinicians prior to the certification or coroners referral process (e.g. nursing homes & hospital wards out of hours). Local policies do apply, familiarise yourself with these so you are able to signpost and inform any family appropriately!
Patient property should be handled with dignity and privacy, consider whether your patient’s next of kin would wish to take responsibility for these? Should valuables be kept in your local safe-box? Could potentially soiled clothing be destroyed? Always remember to document this process for accountability!
Remember to carry out your patient’s personal care in the same dignified fashion as you would any that were living. Many nurses speak to their patient throughout the process! Take care not to apply any restrictive bandaging, strapping or binding. Many departments shall apply multiple forms of identification to include wristbands on alternate limbs, ensure these are correct – and not too tight! Dignify and dress your patient as per local policy, with a shroud or gown.
Coordinate as per your local policy with families for viewing. Is there an area of your department that can facilitate this? Transfer to mortuary with your portering team as soon as possible and appropriate. Is family traveling from afar? Keeping your deceased patient “waiting” in A&E isn’t the most dignified or optimum scenario; remember to continue your advocacy! Consider whether they could visit and liaise with the mortuary technicians at a later time. Our hospital chapel has a room specifically for this purpose!
Whether is your first, or hundredth death in A&E, it always serves to remember that we are human too! Continue to communicate with your team, as our job is like no other. Remember to debrief, vent and “let it out” over a beverage of your choice! Remember to talk about death; we only get one chance to get it right!
References:
- UK Government. (2018) Statistical commentary: End of Life Care Profiles.
- Dahill, M. Powter, L. Garland, L. Mallett M. and Nolan, J. (2013) Improving documentation of treatment escalation decisions in acute care. BMJ Open Quality.
- Park I. et al. (2010) Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. Journal of Emergencies, Trauma and Shock. 3(4) pp. 385-388.
- Ordog, G. (1986) Dealing with Sudden Death of the Emergency Patient. Can Pham Physician. 32(4) pp. 797-802.
- Department of Health. (2009) End of Life Care Strategy: Quality Markers and Measures for End of Life Care.DH: London.
- Gatward, J. (2016) Learning from Sim Part III: Critical Moments in the Intensive Care Unit. Social Media And Critical Care (SMACC); https://smacc.net.au/2019/01/learning-from-sim-part-iii-critical-moments-in-the-intensive-care-unit-by-jon-gatward/
- NHS England. (2017) Guidance for Staff Responsible for Care After Death (last offices).
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