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A Flinders University study has highlighted the challenges and shortfalls in support for our nurses who regularly deliver end-of-life care and comfort bereaved family members in often crowded and chaotic hospital emergency departments (EDs).

The stressful environment, lack of space, and a focus on treatment and cure rather than comfort measures when the patient will not survive are making it difficult for ED nurses to care for dying patients and their families, researchers say in a new study published in Collegian: The Australian Journal of Nursing Practice, Scholarship and Research journal.

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The study also shows that more must be done to help nurses promote their own wellbeing and self-care if they experience the death of a patient.

More than 200 ED nurses in Australia took part in the study by completing an online survey about their experiences.

Lead researcher Dr Adam Gerace, at the time of the study was a Senior Research Fellow at Flinders and is now a Senior Lecturer at CQUniversity, says there are several vital elements when caring for dying patients including a quiet environment, adequate pain control for the patient, the sensitive care of families and their access to the dying loved one.

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“However, nurses in the ED aren’t always able to provide such care to their patients,” Dr Gerace says. “EDs are noisy, there is a lack of privacy and there can be limited time for nurses to talk to family members. This is at odds with how a patient should experience a good death.”

Survey results showed that respondents felt the ED environment is not a suitable place for dying patients, and that they should be transferred out of the ED setting.

Nurses surveyed also reported that the EDs in which they worked were unlikely to have designated areas or rooms for dying patients and their grieving families.

They also strongly agreed it is easier to provide care to dying patients in the ED if the patient has an Advanced Care Directive or an end-of-life care plan.

When asked about the challenges of providing end of life care in the ED, participants spoke of struggles in balancing the competing needs and demands of the high-pressure environment.

“Other critical patients will continue to present to emergency and often can’t wait for intervention. It can become hard to give the dying patient and their family the attention and care they need and deserve with acute and critical patients piling up in the ED,” one participant said.

Almost 5000 people died in EDs around Australia in the 12 months to 30 June 2018. Ninety per cent of these people were triaged at the highest categories – meaning they needed resuscitation or emergency attention within 10 minutes.

However, not all patients who die in the ED have unexpected deaths caused by sudden events such as accidents. For example, a patient may be living with a terminal illness and need to seek medical treatment within the ED.

Co-author Flinders University Emeritus Professor Eimear Muir-Cochrane says the issue is only going to grow as our ageing population increases in Australia and overseas.

“There will be more people with complex health issues who will present to EDs and subsequently die there,” Professor Muir-Cochrane says.

“Emergency departments aren’t staffed or designed to care for dying patients. Therefore, we must focus on the physical environment of EDs, staff training, and more consideration of the toll death takes on frontline nurses.”

More than two thirds of respondents indicated they had received no additional training in providing end of life care.

“This highlights the need for greater education initiatives. We also need to consider the wellbeing and self-care of the nurses themselves,” Professor Muir-Cochrane says.

Dr Gerace agrees, adding that “competence at dealing with death can lead to higher compassion for the patients and their families yet lesser compassion fatigue, and lesser burnout in nurses”.

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