Emergency department nurses reported lack of space, time, and staff as challenges to providing good end-of-life care, according to a recent study.1 Researchers surveyed 1,879 nurses and held focus groups with 17 nurses about care of end-of-life patients, educational needs, availability of resources, and barriers to safe and effective care.
Nurses reported moral distress due to the mismatch between the goals of emergency care and those of end-of-life care. “This type of care is absolutely at odds with the nature of emergency care. What we want to do is fix them and get them out,” says lead study author Lisa Wolf, PhD, RN, CEN, FAEN, director of the Institute for Emergency Nursing Research of the Des Plaines, IL-based Emergency Nurses Association. Other key findings include the following:
• ED nurses reported difficulty with the emotional burden of caring for dying patients.
Some focus group participants expressed that one reason they chose emergency nursing as a specialty was because they didn’t want to have long, painful interactions with dying patients.
“They said, ‘This is not the area of care that I would choose, which is why I’m not a hospice, medical/surgical, or intensive care unit nurse,’” says Wolf.
While ED nurses are trained to “do something and do it quickly,” she says, in the case of terminally ill patients there are no interventions needed except for comfort care. “This is nearly impossible to do in the ED,” Wolf says says. “This is a one-to-one kind of patient.”
• ED nurses are knowledgeable and comfortable with providing quality end-of-life care.
The problem was that they lack time and resources to provide such care. “There was a really pervasive sense that emergency nurses felt strongly that when a chronically ill dying patient comes to the ED, it’s a failure of the system,” says Wolf.
• ED nurses reported moral distress stemming from the inability to provide time-consuming care not only to dying patients, but also their families.
“They wanted to give good care, but were completely stymied from doing so because of the demands of other patients,” says Wolf.
A chaotic, noisy, crowded ED is “a terrible place to die,” says Wolf. “We’ve all had patients who died in hallways. You just feel terrible about it.” Here, Wolf offers the following possible solutions to alleviate moral distress of ED nurses caring for dying patients:
• Improve communication between the ED and community resources.
The goal is for primary care physicians, hospice, and visiting nurse services to understand the need to keep chronically ill patients who are near death out of the ED. “When pain or respiratory symptoms can’t be controlled due to lack of coverage in the community, it’s a failure of the system,” says Wolf.
• Make ED nurses aware of all available resources in the organization.
Some of the focus group participants were unsure if emergency nurses were aware of palliative care services, for instance.
• Have protocols in place to help ED nurses address the needs of dying patients.
ED nurses really wanted a protocol or process to utilize in this scenario, “rather than having to wing it on their own every time,” says Wolf.
For instance, ED policy might instruct nurses to call a social worker or chaplain to the patient’s bedside if palliative care services are unavailable. “Those kinds of procedural things were lacking,” says Wolf.
REFERENCE
- Wolf LA, Delao AM, Perhats C, et al. Exploring the management of death: Emergency nurses’ perceptions of challenges and facilitators in the provision of end-of-life care in the emergency department. JEN 2015: 41(5):e23-e33.
SOURCE
- Lisa Wolf, PhD, RN, CEN, FAEN, Director, Institute for Emergency Nursing Research, Des Plaines, IL. Email: [email protected].
