E.R. = exit required. A philosophical, theoretical, and phenomenological investigation of care at the end-of-life in the emergency department

摘要

Emergency departments (EDs) are places of high-stress, are fast-paced, and are generally a place of transition in the hospital. Patients do not usually stay in the ED and are often transferred to an inpatient unit, transferred to another hospital for a higher level of care, or discharged home. Even though we confront transition in this rescue area, ED clinicians may not be cognizant of the types of death that they attend. The closing of a person's life is the end of a biography, and the person may not ever leave the ED.;The purpose of this interpretive study is to describe the lived experience of ED clinicians' clinical and ethical decision-making, distress, and resolution of actual or potential dying and resuscitative events in an effort to unravel the perceived personal, ethical, cultural, environmental and clinical factors that influence the care of dying ED patients. This interpretive project aims at making explicit caring practices of clinicians and seeking common meaning in ED end-of-life care. This dissertation is a thick description of the ED culture and characteristics, a theoretical examination of end-of-life models, a philosophical investigation of how ED clinicians understand and recognize patients are dying, and how patients approach death and die in the ED. End-of-life research has not focused on end-of-life in the ED. This is a new frontier to be explored.;Chapter Two is a description of ED culture and characteristics with a review, critique, and theoretical examination of the applicability of current end-of-life models to ED care. Current end-of-life models that are based on chronic care or oncology models are difficult to apply in the ED setting. The limitations of these models are that they do not allow for the uncertainty of prognosis or for mortality in sudden illness or injury; do not take in account unpredictability of the course of treatments; and cannot accommodate the suddenness of presentation of illness or injury or the sudden change in patient condition.;Chapter Three is a philosophical examination of end-of-life care in the ED in an effort to help us understand how core medical and nursing values are embodied as care practices and ethical comportment. This chapter integrates Aristotle and other philosophers' notions of phronesis and praxis with Merleau-Ponty's ontological notions of intentional arc and maximum grip in the context of the culture and practices at the end-of-life in the emergency department setting. Chapter Four is a review of phenomenology as a research methodology.;Chapter Five is the dissertation study that describes the seven trajectories of how patients approach death and die in the ED. These seven trajectories are: (1) dead on arrival; (2) resuscitation in the field, resuscitative efforts in the ED, died in the ED; (3) resuscitation in the field, resuscitative efforts in the ED, resuscitated and admitted to the hospital; (4) terminally ill, comes to the ED; (5) frail, hovering near death; (6) arrives at the ED alive then arrests/dies suddenly in the ED; and (7) potentially preventable death by omission or commission.