RESEARCH

WHEN SOMEONE DIES IN THE EMERGENCY

DEPARTMENT: PERSPECTIVES OF
EMERGENCY NURSES
Authors: Kerry-Anne Hogan, PhD, RN, Frances Fothergill-Bourbonnais, PhD, RN, Susan Brajtman, PhD, RN,
Susan Phillips, MScN, RN, and
Keith G. Wilson, PhD, CPsych, Ottawa, Ontario, Canada

Earn Up to 9.5 CE Hours. See page 291.

Introduction: Emergency nurses work in a clinical area where noise, lack of privacy, and the need to manage many patients
treatment measures usually are provided quickly, and they have simultaneously. These nurses were also put in the position of
little time to establish relationships. In addition to performing caring for the suddenly bereaved family members, which was
life-saving interventions, emergency nurses provide care for viewed as an especially challenging aspect of their role.
patients who are dying. Little is known about the experiences of
Discussion: Caring for adults who die in the emergency
emergency nurses who care for patients who die in the
department is a difficult and challenging aspect of the
emergency department in the Canadian context.
emergency nursing role. Emergency nurses believed they did
Methods: This study used a qualitative design with an their best to provide end-of-life care interventions, which
interpretive descriptive approach. Semistructured interviews brought a sense of professional satisfaction. Recommended
were conducted with 11 ED nurses from a large Canadian future interventions include advocating for ED design and
academic health sciences system. physical layout to support compassionate end-of-life care,
provision of policies and training to support families and family
Results: In-depth analysis of the data resulted in 3 major themes:
presence, and support of nursing staff.
“It’s not a nice place to die,” “I see the grief,” and “Needing to
know you’ve done your best.” Findings revealed that emergency
nurses believed the environment made it difficult to care for dying Key words: Emergency nursing; Interpretive description; End-of-
patients and their families because of unpredictability, busyness, life care; Debriefing

ach year, approximately 15 million visits are made to

Kerry-Anne Hogan is Part-Time Professor, Faculty of Health Sciences,

University of Ottawa, Ottawa, Ontario, Canada.
Frances Fothergill-Bourbonnais is Professor Emeritus, School of Nursing,
E Canadian emergency departments, 1 and approximately
70% of persons in Canada die in hospitals. 2 ED visits
create a temporary state of crisis for patients and their family
members. When a patient arrives in the emergency department
Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada.
without vital signs or with a life-threatening illness or injury, urgent
Susan Brajtman is Associate Professor, School of Nursing, Faculty of Health
Sciences, University of Ottawa, Ottawa, Ontario, Canada.
initiation of life-saving interventions is the priority for the health care
Susan Phillips is Geriatric Nurse Specialist, The Ottawa Hospital, Ottawa,
team. However, some patients die in the emergency department as a
Ontario, Canada. result of factors such as advanced age, chronic disease processes, or
Keith G. Wilson is Psychologist, The Ottawa Hospital, Ottawa, Ontario, Canada. traumatic events. Caring for dying patients in all contexts is
Funding support for this study was provided by the CIHR Strategic Training Program identified as one of the most stressful aspects of nursing practice.3
in Palliative Care Research, the RNAO Nursing Initiative, The Camille Reid Palliative How dying patients and their family members are cared for depends
Care bursary, and the Queensway Carleton Hospital Endowment Fund. on whether the death was unanticipated—for example, as a result of
For correspondence, write: Kerry-Anne Hogan, PhD, RN, 2 Pepperidge Way, a traumatic injury—or anticipated, as a result of advancing age or
Kanata, Ontario, K2K 3B4; E-mail: khogan@uottawa.ca. disease progression.4
J Emerg Nurs 2016;42:217-22. A patient’s death in the emergency department creates
Available online 3 October 2015
0099-1767
many additional challenges for nurses because of the constant
Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc.
care demands of acutely ill patients, lack of resources, lack of
All rights reserved. time to prepare for a death, the immediacy of decision making
http://dx.doi.org/10.1016/j.jen.2015.09.003 and interventions, and lack of an established relationship with

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RESEARCH/Hogan et al

the patient and family. For family members, death in the require close or frequent assessment, and a resuscitation room
emergency department usually occurs in crisis, regardless of where critical and unstable patients are treated. The majority of
whether the patient’s death was expected or unexpected, 4 and patients who die in the emergency department are cared for in
emergency nurses bear witness to the intense pain and the resuscitation room.
suffering of suddenly bereaved families. Because of the Individual audio-recorded interviews lasting from 30 to
volume of other patients in the department, time to provide 60 minutes were conducted with the participants and
care to the bereaved family members is limited because nurses transcribed verbatim. Examples of the 9 questions used in the
are expected to move on to care for the next patient. 5–7 semistructured interview were “Can you tell me what it is like to
Although death is a common occurrence in the care for someone who dies in the emergency department?” and
emergency department, it remains under-researched. 8 The “What are some factors that facilitate or hinder caring for
purpose of this study was to describe the experience of someone who dies in the emergency department?”.
emergency nurses who provide care for adult patients who Field notes were recorded during (and after) the
die in the emergency department to better understand the interview and described nonverbal communication and
factors that facilitate care or challenge nurses as they care for parting words that were not captured on the digital
these patients and their grieving families. recorder. This information was embedded in text in the
transcript and contributed to the analysis. The researcher
Methods also maintained a reflective journal that recorded decision-
making steps and personal thoughts to ensure the
An interpretive descriptive approach was used to explore the objectivity of the analysis. All steps of the data analysis
experience of nurses who care for adult patients in the emergency were assisted by and reviewed by the co-investigators. Five
department. Interpretive description is a relatively new qualitative steps of thematic analysis 10 were used to analyze the data:
method developed in the 1990s to provide a credible approach to (1) reading the transcribed interviews and identifying
research questions that cannot be answered using traditional patterns of experience; (2) identifying all the data that
research methods. 9 This type of research design aims to capture related to these classified patterns; (3) moving the related
themes and patterns within the participants’ perceptions of a patterns into subthemes and building emerging themes;
phenomenon and to generate a description that can inform (4) building a justification for choosing the themes; and
practice through greater clinical understanding. Using a (5) formulating theme statements into a story line.
naturalistic paradigm, the intended products of interpretive Rigor and credibility are important components of
design are to provide the profession with a “tentative truth claim” interpretive description 9 and were attained through
about what is common within a clinical phenomenon (such as in-depth knowledge of the phenomenon by the primary
adults who die in the emergency department) and have researcher, the maintenance of a reflexive journal, and
application potential, such as being able to use these findings as consensus of the developing categories and subsequent
a basis for implementing change in clinical practice. themes by the research team. This study was approved by
A convenience sample of study participants were recruited the Research Ethics Board of the participating institution
from 2 emergency departments of a multisite university and the educational institution of the first author.
teaching hospital located in Ottawa, Ontario, Canada. Each of
these emergency departments reports more than 60,000 visits
and more than 200 deaths annually. Both emergency Results
departments aim to practice compassionate family-centered
care and encourage family members to be present at the Six female and 5 male nurses who had experienced multiple
bedside of a dying patient as much as possible. The hospital has deaths in the emergency department volunteered to
a policy that allows families the option of being present with participate in this study. The mean age of participants was
the patient during critical moments, such as during 37.4 years, with an average of 13.6 years of experience in
resuscitation procedures. During these critical events, support nursing and 6.6 years of experience working in an emergency
staff are required to stay with the family throughout the event department. Five of the participants had previous intensive
and must not have a clinical role in patient care. care experience, whereas 3 had worked exclusively in the
The physical layout of the departments includes several emergency department. None had worked on a palliative care
separate treatment areas in which patients are seen according to unit or received any formal end-of-life care education.
their level of acuity and their treatment needs. Both emergency Findings revealed 3 major themes: “It is not a nice place
departments have an ambulatory care area where minor injuries to die,” “I see the grief,” and “Needing to know you’ve done
and illnesses are managed, observation areas for patients who your best” (see the Figure 1). The overriding message of

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these themes was that an emergency department was not an you’re pulled in all different directions” (participant I). Nurses
ideal place to die, but through their provision of care, these felt conflicted after the patient had died because they were
nurses attempted to make an unfortunate situation better. often unable to continue to provide care to the grieving family
Quotes that reflect these themes are presented, and the but were required to move on to the next person, describing
anonymity of the participants has been protected through the nature of their work like a “conveyor belt” (participant J).
the use of nonidentifying initials (eg, “participant A”).
I SEE THE GRIEF
IT IS NOT A NICE PLACE TO DIE
The theme “I see the grief” contained 3 categories: “witnessing
The theme “It is not a nice place to die” reflected the grief,” “peering into people’s lives,” and “seeing beyond the
participants’ view of the ED environment. This theme consisted moment.” “Witnessing grief” described the nurses’ experiences of
of 2 categories: “Emergency is intense” and “Being pulled in all bearing witness to the intense and raw grief of family members.
directions.” The emergency department was described by the All participants agreed that dealing with the death of a patient is
participants as very intense, fast-paced, and busy, with a lack of part of the work of emergency nursing; however, dealing with
space and time to provide compassionate care to dying patients family members after a death and seeing the intensity of their grief
and family members. As participant D noted, “It is just too busy was one of the most difficult situations they faced in their
for patients who are dying. It’s noisy. And there’s too much profession. All participants shared stories of how they were
commotion. It’s not an ideal atmosphere.” sometimes unsure whether they could control their own emotions
Through retelling their stories, nurses expressed frustra- and of feeling helpless for not being able to remedy a situation. As
tion with competing demands and lack of time and felt pulled participant I said, “You see this woman and she’s just falling to the
in all directions. They needed to provide acute care deemed floor and uncontrollably crying and devastated and rightfully
necessary to other patients while also providing care to so…and you can’t say I understand or it will be okay because it’s
patients at end of life, and they described not having enough not going to be okay and at that time, you just cry with her.”
time to establish relationships with patients and family Emergency nurses also were “peering into people’s lives”
members: “With the high acuity in the department, in a sad and often tragic moment. As participant K noted,
sometimes you are unable to do that (meet emotional and “When the family is not around, you’re working on the
physical demands) because your workload is so heavy and patient, you kind of get into your role as a nurse. You do your

FIGURE 1
Themes derived from the study.

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job as an emergency room nurse, but afterwards you see that participants with the opportunity to communicate with their
this person is someone. You see that there is a network of team and validate their role in doing the best they could in the
individuals who are associated to this person and you see the situation. Participant C noted, “You just need to talk it
loss for them. If affects me in the sense that this is a major loss through, people understand your situation. So, when you
for most people and you know that this was someone’s father, don’t get that chance, you go home and you feel depressed
grandfather, etc.…” about not being able to do everything you could have.”
“Seeing beyond the moment” related to the nurses’ In sharing their experiences, participants spoke of how other
ability to see beyond the patient’s death and to what might professionals, primarily other nurses, but also social workers and
lie ahead for the suddenly bereaved. Participants provided chaplains, helped them care for dying patients and families
examples such as organ donation and how it could be because these other members of the team often did not have the
viewed as a positive outcome in a bad situation: “…she immediate workload demands of the nurses. These other
ended up being a donor….something good was going to professionals were able to spend more time offering explanations
come out of this bad situation” (participant A). to families, finding resources, and supporting the emotional needs
of the patient and family members. Participants relied on their
NEEDING TO KNOW YOU’VE DONE YOUR BEST peers to support them in difficult times and in turn provided
comfort for their peers when the roles were reversed. It was
The third theme, “Needing to know you’ve done your through this sharing of experiences and supporting each other
best,” consisted of 2 categories: “Trying to make it better” during difficult times that a unique bond between team members
and “reflecting back.” Through their stories, participants was created. As participant J said, “You do the best you can…
shared how they tried to make the situation better for what keeps me coming back to work…it’s the dedication. It’s the
families by meeting family members where they are in the people I work with. I come to work because I am part of a team.”
grieving process and by allowing the family to be present All of the study participants spoke of the importance of
with their loved one as much as possible. The most leaving work at work and of having an established ritual that
important way the participants tried to make the situation allowed them to do so. It was these rituals that helped the
better was by attempting to create an environment that was participants unwind and put things into perspective. Some of the
private, quiet, and seemingly more peaceful and one in participants shared established rituals such as sitting in front of the
which the patient’s dignity was maintained amidst the TV to unwind, having a glass of wine, or going to the gym or to
chaotic emergency department. As participant J said, “We church. Many participants spoke of the drive home as the key
try to give them their own spot, away from the hubbub, component in leaving work at work. For example, participant H
away from the noise, away from the clatter and chatter. You said, “That’s it, drive home. My 30-minute drive home is enough
basically try to move them to a spot where there is the least for me to unwind, listen to music—LOUD! Do whatever. That
amount of traffic, and that is not always easy.” 30 minutes allows me to leave my work at work.”
When nurses were able to provide family members with Although the ritual was different between participants, all
the opportunity to be at the bedside and say good-bye to a participants described a regularly established routine that allowed
loved one, they felt they had done their job well and that them some time to reflect on their shift and put things into
they were able to provide that family with comfort. perspective. The study clearly indicated that having this time was
Participant I said, “We did everything we could…. It an essential component in their ability to cope with regular events
gives you a certain satisfaction that you’ve managed to allow such as death and to not bring their workplace issues into their
that family member or family to come and say good-bye to personal lives. Participants recognized they could not burden
that family member. It’s emotionally gratifying. It makes themselves with long-term stress or grief but instead needed to be
you feel better because they’re able to have that closure.” able to feel that they had done their best in the situation and be
“Reflecting back” revealed how participants were able to able to put the situation into perspective and move forward.
find meaning and satisfaction in their role and a reason to
continue to practice in the area of emergency nursing by
reviewing events, leaving work at work, and moving forward. Discussion
After a tragic or upsetting death, nurses indicated that
debriefing is important in order to put closure on a patient’s The present study highlights the specific difficulties faced by
death. Debriefing occurred on 3 levels: immediately reviewing nurses who work with dying patients in the emergency
the events with the trauma leader, talking with peers to department and also the need to support family members
acknowledge the importance of teamwork, and ongoing while continuing to meet the needs of other patients. All of
self-reflection. Collectively, these means of debriefing provided the participants in this study spoke of the “competing

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demands” associated with continuous heavy workloads and EMERGENCY ROOM DESIGN
the need to care for many patients and families simulta-
neously. These demands often pulled them away from the Study participants identified the environment as being one
bedside of the dying patient and interfered with their ability to of the most challenging aspects of caring for patients who
support the family in an optimal manner. Moreover, after the die in the emergency department. In designing or
patient died, they were required to resume the nursing care of redesigning emergency departments, it would be beneficial
other patients almost immediately. These demands and the to create a private, quiet area away from the activities of the
need to immediately resume care for other patients did not department that is large enough to accommodate a dying
allow the nurses adequate time to provide optimal end-of-life patient and several family members. A private setting allows
care and to support grieving families. 8,11 These study findings the family members to grieve openly and to be with their
are consistent with the findings of a recent study conducted dying relative without being subjected to the chaos that may
with nurses in 15 emergency departments in Belgium; in that be occurring in other areas. This type of environment would
study, investigators reported that time pressures and physical facilitate a compassionate and caring approach to care
demands were greater in the emergency department than in delivery. Bailey and colleagues 8 identify the need to
general nursing units and that the nurses working in emergency restructure emergency departments to allow for more
departments were frequently confronted with stressful situa- space to enable patients and their family members to
tions that required support from their colleagues. 12 spend time grieving. Further research is needed into the
In the current study, the ED environment was design of emergency departments and the impact on the
described by participants as one of the biggest challenges provision of end-of-life care.
in caring for patients who died because of the physical
layout and the continuous arrival of other patients SUPPORTING FAMILIES
requiring care. The lack of privacy and the busyness of
the ED environment have been described as challenges The participating hospital in this study has a policy that
when caring for suddenly bereaved families. 7,13,14 encourages family presence during critical or tragic moments,
However, physical comfort strategies, as well as manip- and nurses in this study reinforced that this policy was an
ulation of the environment by such means as dimming important aspect of their care. The absence of such a policy
the lights, helped offset these challenges. places emergency nurses in a difficult position when
Participants described ways that they cared for family, confronted with the request of a patient’s family member to
such as by communicating clearly with family members be at the bedside. 11,17,18 Consequently, it is important for
about the patient’s condition, allowing family to be present, organizations to develop and implement a process related to
and encouraging them to say good-bye to their loved one. having family members present during critical moments.
These strategies have also been identified in the literature as
important for end-of-life care. 8,11,13,15,16 In being able to SUPPORTING NURSING STAFF
provide quality end-of-life care, nurses invest themselves in
Workplace stress and its negative effects on health
the nurse-patient-family relationship and are better able to
professionals are important contemporary problems in
manage their occupational stress and create a positive
nursing. 19 Caring for patients who die in the emergency
experience in an event with an undesirable outcome. 8
department is a stressful event that occurs frequently.
Teamwork and debriefing were recognized by the
Informal debriefing after a tragic event was identified by the
participants as helping them deal with dying patients and
nurses as influential in helping them reflect on the incident
their families and enabling them to continue to work in the
and facilitate closure, which, in turn, provided a means to
emergency department. Previous studies highlight the
manage workplace stress. Participants recognized the benefit
importance of being supported by colleagues as an integral
of reviewing the sequences of events after a critical incident
factor in helping nurses cope with tragic events. 3,12
with the team leader to help them validate what went well
with the situation and reflect on what could be improved in
future situations. In addition, nursing peers were able to
Implications for Emergency Nurses acknowledge each other’s feelings and recognize the need of
others to step away from the bedside (even for just a
Implications from this study focus on the design of emergency few minutes) to regain composure. Effective means of
departments and the importance of supporting families and facilitating short debriefing sessions could be beneficial for
nursing staff during and after the death of a patient. all ED staff members.

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RECOMMENDATIONS FOR FURTHER RESEARCH REFERENCES

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