ED observation unit-based delayed comfort care pathway for ED patients on life support

Critically ill ED patients on life support may undergo transition to comfort care as decided by the surrogate decision maker. When several hours are needed for loved ones to arrive and say farewell before initiating comfort care ("delayed comfort care"), these patients require prolonged ED stays or costly intensive care unit (ICU) admissions.

A novel ED observation unit (EDOU)-based delayed comfort care pathway for ED patients on invasive mechanical ventilation and/or vasopressors was created in 2013 at Stanford Hospital. Inclusion criteria are: agreement by the surrogate decision maker to no titration of life support and initiation of comfort care within 18 h of EDOU admission. Exclusion criteria are: potential for organ donation and lack of a private room or nursing resources in the EDOU. Feasibility was assessed by analyzing the electronic health record for all patients who utilized the pathway between 8/2013 and 2/2023. The primary outcome was the proportion of patients who had initiation of comfort care after all expected loved ones arrived to the bedside. We also analyzed patient characteristics, clinical operation data, and safety data.

23 patients were identified in the study cohort. The average patient age was 76, and 48 % were female. Three ED diagnoses for the cohort were intracranial hemorrhage (57 %), cardiac arrest (26 %), and respiratory failure (17 %). All patients were intubated, and six were also on vasopressors on arrival to the EDOU. 100 % of patients had all expected family members arrive to bedside prior to initiation of comfort care. All patients had initiation of comfort care within 18 h of EDOU admission (median time from EDOU arrival to extubation 1.1 h (IQR 0.2-3.2)). No patients had adverse events in the EDOU, died before comfort care initiation, or were transferred to ICU.

The EDOU-based delayed comfort care pathway is a feasible way to deliver compassionate end of life care for patients on life support. It can be considered in hospitals with an EDOU especially if their private ED beds and ICU resources are scarce.