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Emergency department (ED) deaths represent as significant a management concern as they do a major clinical issue. Practitioners and managers often see patient deaths as time-consuming and stressful interruptions in the normal workflow, whether they occur in the prehospital or ED setting.

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Yet death will always be an integral part of the ED milieu. By proactively establishing appropriate policies, implementing targeted education, using protocols, and partnering with other stakeholders, ED managers have the opportunity to improve staff morale, decrease unnecessary and unproductive work, and generate patient and survivor gratitude. The tools exist; management's responsibility is to make them readily available to their staff.

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Managers have the opportunity to positively affect how their staff deal with death by (1) helping to change prehospital practice standards; (2) changing how their staff deal with patients who are dying in the ED; (3) establishing better methods to interact with survivors of patients who die in the ED; and (4) working on other management and educational issues that overlay the clinical setting.

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Dying/Dead Patients—Prehospital

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ED staff may spend significant time managing deaths in the prehospital setting via the EMS units and personnel they supervise. The patients (or surrogate decision makers) frequently do not want resuscitative efforts or further acute medical interventions. Yet standard practice in many areas is to proceed with resuscitative efforts and, in most cases, to transport the patient to the ED. While this may be unavoidable in situations where the death occurs in public, ED leadership has a number of methods to lessen this problem with expected deaths that occur in homes and skilled nursing facilities (SNFs).

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At-Home Deaths

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Expected deaths at home may be associated with patients enrolled in home hospice or receiving other end-of-life treatment. In these cases, neither patients nor their caregivers desire additional, often expensive, discomfiting, and intrusive medical interventions other than palliative care. Yet EMS and police protocols often require that ambulances respond and crews provide treatment and then transportation to the ED. This “last rite” from emergency medical providers is neither welcome nor viewed positively by the public.

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To remedy this situation, managers should consider implementing an easily used, readily available Prehospital Advance Directive (PHAD). This allows the EMS to not institute resuscitative measures in appropriate situations and to permit them to pronounce death on the scene rather than transport the body to an ED. Many PHAD examples exist, with Arizona's statute being a clear and simple model that has been successfully used for nearly 20 years (www.galenpress.com/extras/extra1.htm). Written by an emergency physician, the law's passage demonstrated the type of coalition both useful and often necessary to successfully change existing systems.1 The coalition included the state medical, nursing and bar associations; the AARP; and some elder care groups. Three unique elements of the statute are that it requires only an adult witness rather than a healthcare provider's ...

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