EM · Palliative and end-of-life care in ED
Palliative and end-of-life presentations in the ED
Also known as End-of-life care · Terminal care · Anticipatory prescribing · Death in ED
End-of-life presentations in the ED: recognition via the surprise question, symptom management with morphine/midazolam/haloperidol/antimuscarinic anticipatory prescribing, stopping futile treatment, care after death.
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Red flags
- Use the surprise question early — 'would I be surprised if this patient died within 12 months?' identifies the palliative pathway.
- Anticipatory prescribing at recognition avoids symptomatic death; do not wait until symptoms are unbearable.
- Do not resuscitate a patient with a valid DNAR or advance directive — CPR is not a default.
- Care after death is part of the care — support the family, complete certification, and protect privacy.
Recognition of dying
The surprise question — "would I be surprised if this patient died within 12 months?" — identifies patients who should be on a palliative pathway early, and is validated as a simple prognostic tool in unselected ED patients (12-month AU-ROC 0.72–0.85).[4] ED dying patients carry significant symptom-control needs in pain and dyspnoea, so once dying is recognised, activate anticipatory prescribing rather than waiting.[2][1]
References4ShowHide
- [1]Lindqvist O, Lundquist G, Dickman A. Four essential drugs needed for quality care of the dying: a Delphi study J Palliat Med, 2013.PMID 23234300
- [2]Chua MT, Sen Kuan W, Zheng CQ, et al. Validation of Care of the Dying Evaluation in Emergency Medicine (CODE-EM) Ann Palliat Med, 2021.PMID 34118856
- [3]Kompanje EJ, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life Intensive Care Med, 2008.PMID 18516588
- [4]Theunissen M, Lardenoye S, et al. The surprise question: predictive accuracy in an unselected emergency department population - a prospective study in nurses and physicians. Ann Med, 2025.PMID 40665801