Table 8 Themes and categories

Providing palliative and EOL care in the ED is challenging

• Medical conditions associated with needing palliative care.

• Recognition of special care needs of EOL patients; need to treat patient and care for family.

• Challenges due to staff having expertise in emergency medicine rather than treating patients with palliative care needs.

• Inappropriate physical environment.

Patients go to the ED due to challenges in community management

• Decision, often inappropriate, by GP, nursing home/hospice staff or paramedics.

• Should be cared for at home by community teams/poor management in the community.

• Patient/family unable to see GP/contact community services, especially out of hours.

• Family cannot cope with patient struggling at home.

Health system influences admission and discharge decisions

• Patient/family’s wishes (may be expressed in ReSPECT/ACP).

• It is easier to admit than discharge.

• Medical needs of patient changing.

• Availability of hospital and community support; linked to time of day.

• Practical reasons e.g. no beds, may admit if long wait time, including above the four hour requirement.

Discussion with patient about treatment and EOL care needs to be outside of the ED

• Knowing patients’ wishes about treatment through a ReSPECT form or ACP makes it easier for medical staff.

• If no record of a patient’s wishes, may be given all investigations and CPR.

• ED consultants routinely discuss EOL treatment with patients and complete the ReSPECT form.

• ED is not the right place to have a conversation about dying; needs to at an earlier stage, outside the ED.

• There may be a conflict between the patient’s verses the family’s wishes.

Improving services for patients with palliative care needs

• Need to be able to access staff with expertise/responsibility for palliative care.

• Regular short training/information sessions for ED staff.

• Discussions with patients and completion of ReSPECT or ACP outside of ED, before EOL care is needed.

• Information to patients/families on services/support available in the community.