Death trajectories and treatment decisions in emergency departments: evaluating the effects of the life-sustaining treatment decision act

Background: The emergency department (ED) is not ideal for end-of-life care; however, unavoidable deaths arising from sudden death, severe chronic illness, and advanced frailty do occur. Treatment approaches, ranging from full life-support treatment to comfort-focused care, vary according to these causes. This study aimed to analyze the death trajectories (DTs) and treatment decisions in patients who died in the ED after the implementation of the Life-Sustaining Treatment (LST) Decision Act. Methods: This retrospective study included patients aged ≥18 years who died in the ED of two tertiary care hospitals from 2018 to 2022. By reviewing electronic medical records, the DT was categorized based on specific criteria. We analyzed the treatment direction, decisions on LST withdrawal, and care received in the ED. Results: During the study, 2996 patients died in the EDs of the two hospitals. Of these, 1432 patients did not experience cardiac arrest upon ED admission, while 1564 patients did. In patients with out-of-hospital cardiac arrest, between 78.8% and 97.1% received full life-support treatment, depending on the specific DT. Approximately 50% of patients with chronic serious illness or advanced frailty received comfort-focused treatment. Of the 292 patients who completed LST plans, only 12.7% opted for self-determination. Conclusions: This study highlights a lack of advanced care planning for end-of-life patients. For patients with severe chronic illness or advanced frailty, proactive preparations for comfort-focused treatment options, such as LST plans, are recommended based on patient autonomy. Appropriate ED workflow systems are crucial to providing high-quality end-of-life care to patients with irreversible conditions and imminent death, particularly to those in the last hours or days of life.

Emergency service hospital; Life support care; Chronic disease; Personal autonomy; Advance care planning; Resuscitation order

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