Dying patients in the ED: best practices for providing comfort care

  • Wang D & al.
  • J Emerg Med
  • 29 Dec 2018

  • curated by Jenny Blair, MD
  • Clinical Essentials
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  • If medical care is futile, emergency physicians (EPs) should “transition to comfort care.” 
  • Aggressively managing symptoms, minimizing disturbances, and not abandoning patient and surrogates are crucial to compassionate care for dying.

Why this matters

  • ED physicians should discuss comfort care “when ED care approximates futility, either imminently or in anticipated downstream hospital course,” authors say.


  • Systematic review of literature on symptom palliation, care coordination for acutely dying patients.

Key details

  • Grieving starts before death; ED staff can influence family’s experience. 
  • Advanced directive can begin conversations.
  • Consult risk management if surrogate-document conflict arises.
  • “Transition to (aggressive) comfort care” is preferred phrasing over “withdrawal of care.”
  • “There is nothing more that can be done” is never true; patients and surrogate suffering can be eased.
  • Prognostic signs: sagging jaw, pulselessness, Cheyne-Stokes respirations, apneic pauses.
  • Symptom management:
    • Pain, dyspnea: bolus opioids; reassess; benzodiazepines are second-line for dyspnea;
    • In awake patients losing airway, sedate to unconsciousness;
    • Terminal delirium: benzodiazepines, antipsychotics; 
    • Secretions: anticholinergics.
  • Before extubation, stop pressors, fluids, mechanical circulatory support; deactivate cardiac devices; bolus comfort medications, especially if patient triggers breaths, has cough, gag.
  • Involve nurse, respiratory therapist, social worker, chaplain.
  • Stop monitors, alarms; allow visitors; minimize disturbances. 
  • Periodic reassessment mitigates feelings of abandonment.

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