Professor Patrick Plunkett:

Death is the only certainty in life. Whether one includes taxes, as did Benjamin Franklin, is a moot point as there may be ways to avoid taxes but none to avoid death.

End-of-life care in the emergency department is a recently coined phrase but the concept predates all of those in this room. Most people who contemplate the end of their own lives fear certain aspects of it, in particular the risk of pain or indignity. Whereas it was common up to 50 years ago for people in this country to die at home, it is increasingly uncommon. Some 48% of deaths occur in acute hospitals, 20% in long-term care facilities, 25% at home and only 4% in hospice care. When expected, arrangements may be in place to deal with the concerns of the dying person and their relatives. When unexpected, or precipitate, such plans may be thwarted or simply not yet in place. Interestingly, surveys have shown that most medical doctors would opt to die at home, if at all feasible.

An audit study from four years ago showed that 84% of patients dying in hospital had accessed the hospital via the emergency department, with 24% of the deaths being unexpected. End-of-life care in the emergency department is opportunistic in that it depends on many factors coming together at the one time. It relies on the determination of the staff to ensure the best possible experience for their patients and the patient’s relatives or friends. It requires determination to deliver quality care in what is perceived by many outsiders as a chaotic setting. Every dying person has physical, psychological, social and spiritual needs. It is relatively uncommon for one person to be able to support each and every one of these needs. Instead, a team effort is essential. This team must be prepared and, like an elite squad, practised at its task.

The barriers to a high quality death in the emergency department include the physical setting, often overcrowded, noisy, and with high intensity lighting 24 hours a day. It is psychologically extremely difficult to be plucked from one’s bed at home, gasping for breath, and be brought by ambulance, careening through the streets with sirens blaring, to a noisy environment, where the bustle of life-saving measures applied to one person may interfere with the peace and quiet required by a dying woman contemplating her last few hours or minutes on this earth. There is an understandable reluctance to spend a lot of time with a person known to be dying, whose life cannot be prolonged by any means within the power of nursing and medical staff. While staff are concerned for these people, the pressure of other patients’ needs can be very distracting, running the risk of a lonely death in a crowded room.

What of the tensions within a family whose loved one has been injured in a traffic collision or in a murderous assault and now lies sedated, ventilated and paralysed, unable to communicate his or her needs, with no prospect of survival? All deaths in the emergency department or within 24 hours of admission must be reported to the Coroner. Post mortem autopsies will be carried out on a high proportion of these, otherwise the legal requirements for death certification will not be fulfilled.

This places further tension on the relations between families and staff, which can, on occasion, lead to difficulty.

What can be done to optimise end-of-life care in emergency departments? The first thing is to believe it can be improved, to examine each element carefully and to deal with every deficiency in a constructive fashion. The environment of the emergency department is designed for large-volume patient care, in a physically constrained area. To reduce the inevitable noise, bustle and excess light, requires a separate area that can be used to support patients and their families during the process of dying and after death. This needs to be close enough to the main clinical area to allow ready access with staff able to move to and fro without difficulty. It should be decorated in calm and soothing colours and fabrics, while keeping in mind the infection control elements required in a clinical environment. Access to refreshments and to external communications for families is vital. Nowadays, this means ensuring adequate mobile phone signal strength, which can be a difficulty in areas with radiation protection built in to the walls.

Staff, whether medical, nursing, clinical or clerical-support personnel, must be all trained in the ways they can support dying people and their families. At this moment a seminar it taking place in my hospital to teach people how to break this barrier of dealing with dying patients. Rather than end-of-life care, it is called "journeys". It equally means the staff must face their own inevitable death, at least in broad philosophical terms.

There must be a willingness to engage with the physical, emotional and spiritual needs of patients, whatever the religious beliefs of the staff. This is increasingly important in an Ireland which 50 years ago had mainly Roman Catholics and Protestant denominations with a smattering of Jewish people, but which now has many other different religious groups, ranging thorough Animist, Buddhist, Coptic, Christian Orthodox, Daoist, Episcopalian, Hindu, Sikh, Muslim and others.

Unless the inevitability of death is recognised, there may be a reluctance to use adequate doses of powerful painkillers despite clear evidence of need. However, access to adequate pain relief is a must for those who have pain. Methods to enhance this include the use of technology, such as patient-controlled analgesic pumps or transcutaneous pain relief and the use of personnel, such as pain-control or palliative-care specialists. The latter are rarely available on a 24-hour basis, but can provide tuition for those who are, such as medical and nursing staff in emergency departments, who can then use the technology as required.

These issues might be better dealt with if there was a more open and structured approach to end-of-life-care planning at personal and family level. If a person is discharged from hospital to home with a known terminal illness, there seems to be a reluctance to engage with the person and his or her family to understand the next step in the process. This leads to panic when the patient eventually and inevitably deteriorates at home. The family or friends then lose control and dial the emergency number for the ambulance service. Once that behemoth is unleashed, the result is predictable - the patient will be brought to the nearest emergency department, usually in extremis. He or she will then die in the emergency department or during the journey.

In cases where the patient has already suffered a cardiac arrest, there is a natural reluctance on the part of pre-hospital emergency care providers - ambulance personnel - to pronounce death in the home, which leads to ongoing resuscitative efforts and pronouncement of death in the emergency department. That then leaves the emergency department team to deal with the process of informing relatives and dealing with their grief, and with the logistic difficulties of identification and referral to the coroner. Although the Pre-Hospital Emergency Care Council has developed a clinical practice guideline to reduce this problem, it is likely to remain an issue into the future. I understand that my colleague, Dr. King, will deal with that.

An increasing concern for emergency medicine practitioners is the apparent reluctance to allow frail elderly men or women die peacefully in nursing homes. Hypostatic pneumonia, which leads to delirium and death over a period of a few days used to be termed "the old man's friend". Once secretions were dealt with, the patient turned regularly to reduce discomfort and pain prevented by the use of "the Brompton cocktail", the patient would slip away quietly, with their relatives and friends by the bedside. This no longer occurs.

A similar issue also affects demented elderly patients who fall in nursing homes or who develop urinary tract infections and sepsis. The perceived underlying cause is the risk of an adverse comment from the coroner or, worse still, from a HIQA investigation into increasing numbers of deaths in that nursing home. The fallout from Lees Cross has had both positive and negative effects in this regard in my view.

Very few emergency departments in this country have adequate physical facilities for death and bereavement, although these facilities are, in fact, cheaper to provide than acute clinical space. The necessary investment is small relative to the overall health budget, but the potential good for the lives of those who have been bereaved is enormous. The possibility remains that good bereavement care will lead to shorter, less-intense grief responses and lower levels of psychological ill health afterwards.

What can the Oireachtas committee do? It can probably only encourage health policy that supports good end-of-life care, including early bereavement care, within emergency departments. Ensuring that it is on the agenda for health-care planning is critical to developing a response from planners, managers and clinicians that will lead to a greater, more positive, societal impact.

It behoves us all to consider how and where we would wish to die and to plan for "a good death" on a personal basis. Once such a plan is devised, it should be shared with others, such as the next-of-kin and the family doctor, with clarity achieved on the wishes of the person involved. Using the "think-ahead" template developed by the forum on the end of life and supported by the Irish Hospice Foundation is a readily accessible way to deal with this issue. It is important to ensure access to this on a 24-hour-a-day basis, ideally in a central online register, to ensure that appropriate levels of care and comfort can be provided consistent with the wishes of the person and his or her current clinical status. Ideally, every competent person entering a nursing home for long-term, end-of-life care should be provided with support to fill in that template.

A peaceful, timely death at home or in a nursing home should be seen as the norm, rather than an aberration and a failure of the health care system. Ultimately we will all die, but there are ways in which we can make that a much more palatable and acceptable process of transfer.