Background Every day, Emergency Department (ED) doctors are confronted by the challenges associated with patients who are dying or who are nearing the end of life. Recognising that a patient is dying and identifying the need for a more palliative approach is crucial if the patient is to receive appropriate end of life care. Such decision making in the ED will also minimise harm to this patient group by avoiding treatments which would be futile, burdensome or contrary to the patient‘s wishes.

Method A communication tool was devised for use in the ED (named Hospital Anticipatory Care Plan - HACP). It allowed for the attending ED doctor to document what they felt were appropriate treatment options and also level of escalation in terms of any ITU/HDU referral. If considered that end of life care was most appropriate then this could also be indicated. Training in use of the tool was provided for medical and nursing staff of all grades.

Results One year after introduction of HACP, the tool is now commonly used in conjunction with DNACPR. An audit of cases admitted through the ED with HACP completed showed that in 73% of cases the patient died within 48 hours of admission - without being subjected to futile interventions or inappropriate escalation of care.

Conclusions Senior ED staff have fairly reliable clinical acumen in identifying patients who are on an end of life trajectory. Recognising that a patient is nearing the end of life makes it less likely that a patient will have a “bad death” ie, one that involves futile over treatment of their underlying condition while under treating their palliative needs.