For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
The emergency department is a challenging environment for end-of-life care, presenting ethical and quality of life issues. Research indicates that over 50% of Australians who die an ‘anticipated’ or ‘expected’ death, will die in acute hospitals, even though the majority approaching end-of-life wish to die at home. In this context, clinicians, patients and their families should work together to ensure they have a common understanding of the goals of care. Values and wishes around medical treatment should be documented. Monitoring and investigations should be appropriate. Clinicians should advocate for the patient by initiating discussion about end-of-life care with inpatient clinicians and community health professionals. When possible, arrange for end-of-life patients to be transferred to a palliative care facility to avoid admission to acute wards.
- Lukin W, Douglas C, O’Connor A. Palliative care in the emergency department: An oxymoron or just good medicine? Emerg Med Austral 2012;(24):102–4.
- Forero R, McDonnell G, Gallego B, McCarthy S, Mohsin M, Shanley C, Formby F, Hillman K. A Literature Review on Care at the End-of-Life in the Emergency Department. Emerg Med Internat 2012;1-11. Article ID 486516
- Australasian College for Emergency Medicine. 2015. Curriculum Framework.
A Choosing Wisely Working Group of 9 emergency physicians identified an initial list of 10 potential items. All ACEM members were able to provide feedback on these items and suggest other issues for consideration. This feedback informed Working Group refinement of the initial list into 8 recommendations. Evidence reviews were then completed for each recommendation. These evidence reviews, frequency of use in ED, risks/benefit to patient and cost were used as criteria for Working Group member voting in order to determine the final 6 recommendations. These recommendations have been endorsed by ACEM's Council of Advocacy, Practice and Partnerships.
Following identification of two common recommendations with the Royal Australian and New Zealand College of Radiologists, it was agreed by both Colleges to jointly present these items.
Avoid requesting computed tomography (CT) imaging of kidneys, ureters and bladder (KUB) in otherwise healthy emergency department patients, age <50 years, with a known history of kidney stones, presenting with symptoms and signs consistent with uncomplicated renal colic.
Avoid coagulation studies in emergency department patients unless there is a clearly defined specific clinical indication, such as for monitoring of anticoagulants, in patients with suspected severe liver disease, coagulopathy, or in the assessment of snakebite envenomation*.
- 3 Avoid blood cultures in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid, or joint aspirate) is possible.
- 4 For emergency department patients approaching end-of-life, ensure clinicians, patients and families have a common understanding of the goals of care.
- 5 Don’t request imaging of the cervical spine in trauma patients, unless indicated by a validated clinical decision rule.
- 6 Don’t request computed tomography (CT) head scans in patients with a head injury, unless indicated by a validated clinical decision rule.