(366) Delayed Comfort Care in an ED Observation Unit

Monday, February 24, 2025

11:30am – 12:30pm Eastern Time

Location: Connections Central - RST 01

First Author(s)

JS

Jiayin Sun, MD

Stanford Health Care, USA

Co-Author(s)

MD

Melissa D'Souza, MD

Geriatrician/Critical Care Physician
Lawrence General Hospital, United States
ML

Michael Losak, MD

Clinical Assistant Professor
Stanford Health Care, United States
Natalie Htet, MD, MS (she/her/hers)

Stanford University Medical Center
Stanford University, California, United States
Tsuyoshi Mitarai, MD (he/him/his)

Clinical Professor
Stanford University Medical Center
Palo Alto, California, United States

Introduction: Critically ill emergency department (ED) patients may transition to comfort care after an ED resuscitation that includes mechanical ventilation and/or vasopressors (“life support”). This transition is usually initiated by the surrogate decision-maker after ED diagnostics. When time is needed for loved ones to arrive and say farewell before discontinuing life support and initiating comfort measures (“delayed comfort care”), these patients require prolonged ED or costly intensive care unit (ICU) stays.

Methods: An ED observation unit (EDOU)-based delayed comfort care pathway for ED patients on life support was created in 2013 at Stanford Hospital. Inclusion criteria: patients on life support with desired transition to comfort care, agreement to no life support titration, and initiation of comfort care within 18 hours of EDOU admission. Exclusion criteria: potential for organ donation and lack of a private room or nursing resources in the EDOU. Feasibility was assessed by analyzing the electronic health record for all patients who utilized the pathway between 8/2013 and 2/2023. The primary outcome was the proportion of patients who had initiation of comfort care after all expected loved ones arrived to bedside. We also analyzed demographic, clinical operations, and safety data.

Results: 23 patients were identified in the study cohort. The average patient age was 75.8 ± 11.5 (SD), and 48% were female. ED diagnoses related to entry into the pathway were intracranial hemorrhage (57%), cardiac arrest (26%), and respiratory failure (17%). All patients were intubated, and six were also on vasopressors on arrival to the EDOU. 100% of patients had all expected family members arrive to bedside prior to initiation of comfort care. All patients had initiation of comfort care within 18 hours of EDOU admission (median time from EDOU arrival to extubation 3.5 hours (IQR 1.2 - 4.6)). No patients had adverse events in the EDOU, died before comfort care initiation, or were transferred to ICU.

Conclusions: The EDOU-based delayed comfort care pathway is a feasible way to deliver compassionate end of life care for patients on life support. It should be considered in hospitals with an EDOU especially if their private ED beds and ICU resources are scarce.