Revisiting Comfort-Directed Therapies: Death and Dying in the Emergency Department, Including Withholding and Withdrawal of Life-Sustaining Treatment

End-of-life issues arise frequently in the emergency department (ED). Patients and their caregivers arrive with requests for pain relief and other symptom management, need for life-sustaining interventions, or seeking options to control suffering experienced in the dying process. Some patients will arrive without prior planning, or will change their preferences for various reasons, including the influence of others. Their goals for intervention should be elicited early on in the care episode. Few will arrive with clearly defined goals and expectations, although the genesis of the dying patient's problem predates the ED visit in the trajectory of illness. Consequently, most palliative care is best integrated alongside active therapies aimed at prolongation of life and cure. Ethically, emergency physicians may appropriately withhold or withdraw life-sustaining interventions in the ED, if doing so removes treatments that do not work, are not wanted, or have become overly burdensome to the patient, but providing comfort-directed measures should continue without interruption, and clinical guidance in this area exists. This chapter discusses some of the relevant end-of-life ethical issues that have a legal basis, including US federal law ensuring the right to seek emergency care, public policy and research in the area of pain control, and the data and utility of advance directives. The evidence for life-prolonging treatment or symptom management in advanced cancer, as the rationale, for frequent ED visits at the end of life is reviewed. The chapter offers a 10-point checklist, based on the American College of Emergency Physicians (ACEP) detailed policy to enhance end-of-life care, which fits into a basic conceptual framework keyed for busy clinicians to approach end of life and gives related guidance for comfort-directed therapies. The chapter also reviews and differentiates the ethical and legal permissibility of withholding and withdrawing life-sustaining treatment and accepted comfort measures (i.e., palliative sedation) from that of physician-assisted suicide and euthanasia.