Trajectories of approaching death in the emergency department: clinician narratives of patient transitions to the end of life.

CONTEXT: Transitions near the end of life have not been well articulated and the end-of-life (EOL) phase is not well understood in the emergency department (ED). The sudden and unforeseen is common in the ED.
OBJECTIVES: The purpose of this qualitative research project is to identify different trajectories of approaching death in an effort to describe the EOL experience in the ED.
METHODS: An interpretive phenomenological approach was used to assess the results of interviews with and observations of ED staff who were intimately involved in caring for patients approaching death and dying.
RESULTS: Seven trajectories of approaching death in the ED emerged from the data: 1) dead on arrival; 2) prehospital resuscitation with subsequent ED death; 3) prehospital resuscitation with survival until admission; 4) terminally ill and comes to the ED; 5) frail and hovering near death; 6) alive and interactive on arrival, but arrests in the ED; and 7) potentially preventable death by omission or commission.
CONCLUSION: A descriptive articulation of the various trajectories will help clinicians be more astute in their recognition of the clinical situation and react appropriately, will help identify the transitions to the EOL phase, and will help to explore the possibilities open to the patient, family, and clinicians. In addition, understanding the trajectories and discussion of the clinicians' actions and communication strategies can elucidate which of the trajectories could benefit from anticipatory planning.