Operational end-of-life trajectory categories among patients who died in the emergency department: associations with resuscitative and palliative care in a five-year retrospective cohort

Background: Emergency departments (EDs) increasingly care for patients approaching the end of life, yet the relationships between patterns of decline and final ED care remain poorly characterised. The objective was to describe the distribution of retrospectively assigned trajectory-oriented categories among ED decedents and examine associations with care processes. Methods: This single-centre retrospective cohort study included adults who died in the ED between 2018 and 2022. Categories were acute event/low comorbidity (T1), terminal malignancy or pre-existing exclusive palliative/comfort-focused care (T2), advanced chronic disease with acute decompensation (T3), frailty/dementia or high comorbidity with severe functional dependency (T4), and residual unclassified cases (T5). Primary outcomes were CPR and documented initiation of exclusive palliative/comfort-focused care; documented end-of-life recognition or discussion was secondary. Results: Of 628 patients, 1.3% were T1, 10.8% T2, 10.0% T3, 49.4% T4, and 28.5% T5. CPR ranged from 75% in T1 to 24% in T2 and T4 (p<0.001). Exclusive palliative/comfort-focused care was initiated in 35% of T2 and 11% of T3-T5 patients (p<0.001). End-of-life recognition or discussion ranged from 12% in T1 to 51% in T2 (p=0.034). Conclusion: Frailty and dementia represented the main trajectory of death in the ED, while nearly one-third of patients could not be classified within the predefined categories. A pragmatic trajectory-oriented framework may help interpret observed patterns of care. However, retrospective assignment and the large residual group make these findings hypothesis-generating; prospective validation is required before decision-support use.

Background Emergency departments (EDs) increasingly care for patients approaching the end of life, yet the relationships between patterns of decline and final ED care remain poorly characterised. The objective was to describe the distribution of retrospectively assigned trajectory-oriented categories among ED decedents and examine associations with care processes.Methods This single-centre retrospective cohort study included adults who died in the ED between 2018 and 2022. Categories were acute event/low comorbidity (T1), terminal malignancy or pre-existing exclusive palliative/comfort-focused care (T2), advanced chronic disease with acute decompensation (T3), frailty/dementia or high comorbidity with severe functional dependency (T4), and residual unclassified cases (T5). Primary outcomes were CPR and documented initiation of exclusive palliative/comfort-focused care; documented end-of-life recognition or discussion was secondary.Results Of 628 patients, 1.3% were T1, 10.8% T2, 10.0% T3, 49.4% T4, and 28.5% T5. CPR ranged from 75% in T1 to 24% in T2 and T4 (p<0.001). Exclusive palliative/comfort-focused care was initiated in 35% of T2 and 11% of T3-T5 patients (p<0.001). End-of-life recognition or discussion ranged from 12% in T1 to 51% in T2 (p=0.034).Conclusion Frailty and dementia represented the main trajectory of death in the ED, while nearly one-third of patients could not be classified within the predefined categories. A pragmatic trajectory-oriented framework may help interpret observed patterns of care. However, retrospective assignment and the large residual group make these findings hypothesis-generating; prospective validation is required before decision-support use.