RESEARCH
EXPLORING THE MANAGEMENT OF DEATH:
EMERGENCY NURSES’ PERCEPTIONS OF
CHALLENGES AND FACILITATORS IN THE
PROVISION OF END-OF-LIFE CARE IN THE
EMERGENCY DEPARTMENT
Authors: Lisa A. Wolf, PhD, RN, CEN, FAEN, Altair M. Delao, MPH, Cydne Perhats, MPH, Paul R. Clark, PhD, MA, RN,
Michael D. Moon, PhD, RN, CNS-CC, FAEN, Kathy M. Baker, PhD, RN, NE-BC, Margaret J. Carman, DNP, ACNP-BC, CEN,
Kathleen E. Zavotsky, MS, RN, CEN, ACNS-BC, CCRN, and Gail Lenehan, EdD, MSN, FAEN, FAAN, Des Plaines, IL,
Louisville, KY, San Antonio, TX, Richmond, VA, Durham, NC, New Brunswick, NJ, and Boston, MA
Introduction: The importance of end-of-life (EOL) care for
dying patients and their families is well described; however,
little research has been performed in emergency settings. The
purpose of this study was to explore emergency nurses’
perceptions of challenges and facilitators in the care of patients at
the EOL.
Methods: A mixed-methods design using survey data (N =
1,879) and focus group data (N = 17). Data were collected on
questions regarding care of the EOL patient in the emergency
department, specifically nurses’ perceptions of the care of these
patients; educational content needs; barriers to safe and
effective care; and the availability of resources.
Results: High scores on the quantitative survey showed
a high mean level of consistently positive attitudes and
beliefs toward caring for dying patients and their families and
loved ones (131.26 ± 10.88). Analysis of the focus group
Lisa A. Wolf, Member, Pioneer Valley Chapter, is Director, Institute for Emergency
Nursing Research, Emergency Nurses Association, Des Plaines, IL.
Altair M. Delao is Senior Associate, Institute for Emergency Nursing Research,
Emergency Nurses Association, Des Plaines, IL.
Cydne Perhats is Senior Associate, Institute for Emergency Nursing Research,
Emergency Nurses Association, Des Plaines, IL.
Paul R. Clark, Member, Kentuckiana Chapter, is System Educator, Norton
Healthcare Institute for Nursing, Louisville, KY.
Michael D. Moon, Member, San Antonio Chapter, is Assistant Professor, University
of the Incarnate Word, San Antonio, TX.
Kathy M. Baker, Member, Central Virginia Chapter, is Nursing Director, VCU
Health System, Richmond, VA.
Margaret J. Carman, Member, Cardinal Chapter, is Assistant Professor, Duke
University School of Nursing, Durham, NC.
September 2015 VOLUME 41 • ISSUE 5
transcripts uncovered 9 themes, reflecting concerns around
comfort and challenges with EOL care, appropriate training
for nurses, and the availability of resources to provide this
type of care in the emergency setting. Also noted was
dissonance between the nature of emergency care and the
nature of EOL care.
Discussion: Emergency nurses are comfortable providing EOL
care in the emergency setting but note that challenges to
providing good care include lack of space, time, and staff. Other
challenges involve the mismatch between the goals of
emergency care and those of EOL care, as well as the
emotional burden of caring for the dying, especially when the
appropriate resources are lacking.
Key words: Mixed methods; End-of-life care; Emergency
department; Nursing.
Kathleen E. Zavotsky, Member, West Central New Jersey Chapter, is Director,
Nursing Research, Advanced Practice and Education, Robert Wood Johnson
University Hospital, New Brunswick, NJ.
Gail Lenehan, Member, Mayflower Chapter, is Clinical Nurse
Specialist, Massachusetts General Hospital, Boston, MA.
For correspondence, write: Lisa A. Wolf, PhD, RN, CEN, FAEN,
Emergency Nurses Association, 915 Lee St, Des Plaines, IL 60016;
E-mail: lwolf@ena.org.
J Emerg Nurs 2015;41:e23-e33.
0099-1767
Available online 30 July 2015
Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2015.05.018
WWW.JENONLINE.ORG e23
RESEARCH/Wolf et al
Nurses are there when the last breath is taken and
nurses are there when the first breath is taken. Although it
is more enjoyable to celebrate the birth, it is just as
important to comfort in death.
Christine Bell
he emergency department is a care setting where
T patients are essentially unknown and potentially
acutely ill or injured, and the emergency nurse can
be the driver of care and advocacy for these patients.
Because rapid assessment and delivery of resources are
crucial to reduce morbidity and mortality rates, the impetus
is to “do something.” However, the process of providing
end-of-life (EOL) care for dying patients and their families
is understudied, and there is little research available to
support the role of the emergency nurse in caring for this
population. 1 Relationships that can be built up over days
and weeks in the inpatient or hospice setting must be
formed in hours or minutes in the emergency department.
The fast-paced, resource-challenged ED setting can
compromise the EOL experience for patients seeking
emergency services and the nurses who care for them. To
address these concerns, the 2011 Improving Palliative Care
in the ICU and Emergency Medicine Project (IPAL-EM)
developed a consensus statement on necessary competen-
cies for EOL care that includes recognition of the
appropriate patient, as well as provision of respectful,
scientifically based palliative care for both the patient and
the family. 2 Though offering a useful framework in the
intensive care unit and inpatient or hospice settings, the
time, space, and resource constraints of the emergency
department may make implementation of this part of EOL
nursing practice challenging. Specific to EOL emergency
care is the Trauma End-of-Life Optimum Support
(TELOS) model of best practices for providing EOL
support for trauma patients seen in the emergency
department. 3 It is composed of 6 domains: decision
making, communication, physical care, psychological care,
spiritual care, and culturally sensitive social care. What is
still lacking, however, is a process for caring for the acutely
ill dying patient who presents to the emergency department
with chronic, life-limiting illness. 4 In these cases the
patient’s condition is not new, as with the trauma patient;
the patient may be a hospice patient who is dying or whose
pain cannot be controlled and is brought to the emergency
department by family members. In these situations,
challenges to optimal EOL care are potentially magnified
by the constraints of the ED setting.
In an observational ethnographic study on EOL care in
a large, urban emergency department in the United
Kingdom, 5 2 distinct trajectories of care for dying patients
e24 JOURNAL OF EMERGENCY NURSING
were identified: the sudden, or “spectacular,” death in which
the focus was on life-saving, heroic measures and the
“subtacular” death in which patients with terminal illness
received less attentive care. Through corollary research, the
authors explain how these care trajectories were influenced
by clinicians’ attitudes and practices toward death and dying 6
and by their “emotional intelligence”—the ability to manage
emotions and develop the interpersonal and therapeutic skills
necessary for quality EOL care. 7 These capabilities can
influence the nurse/patient experience.
Other research that focused on nurses’ perceptions of
obstacles and supportive behaviors in critical and emergency
care settings identified similar challenges to the provision of
quality EOL care, including nurse workload and availability
of support services (eg, social workers and clergy); family
issues (eg, unrealistic expectations and distraught family
members); environmental constraints (eg, poor space design
and lack of privacy); and concerns about honoring patients’
wishes (eg, uncertainty about decisions regarding desired
treatment and advance directives). 8–10 The literature
includes suggestions from emergency clinicians, patients,
and family members on how to address these challenges
to EOL emergency care, such as integration of EOL
curricula in nursing school education 11–14; increased
time and adjunct resources (eg, social workers and
palliative care) 8,9,15; cultivation of positive clinician-patient
interactions and nurse-physician communication 7–9,15;
and changes to the ED environment to provide privacy
and support for grieving families. 6,10,15 In addition, the
IPAL-EM group put forward a series of guidelines for
providing palliative care in the emergency department
that align well with the aforementioned issues identified
by patients, families, and health care providers. 16 Our research
goals are consistent with these previous research recommen-
dations, specifically regarding our study’s aim to further
examine emergency nurses’ attitudes/beliefs, educational
needs, and resource allotment regarding EOL emergency care.
Methods
This study used an exploratory mixed-methods design
incorporating a self-report survey and focus group inter-
views for additional context and explanation. A demo-
graphically diverse sampling method was chosen to increase
the range of clinical experiences captured. Data were
collected and analyzed concurrently with equal weight
initially given to survey and focus group results. The
mixed-methods approach was chosen because of the
complex nature of the research question, for which the
use of combined quantitative and qualitative data provides a
more complete understanding than either approach alone. 17
VOLUME 41 • ISSUE 5 September 2015

A comparison and synthesis of integrated study findings are
provided in the Discussion section. Before data collection,
the Chesapeake Institutional Review Board (IRB) reviewed
the protocol and determined that the study was exempt
from IRB oversight.
QUANTITATIVE
Self-Report Survey
Survey data were collected online using Qualtrics software
(Provo, UT) and included demographic information
specific to both the participant (eg, age, gender, educational
level, and experience in emergency nursing) and the facility
in which the nurse worked (eg, number of ED beds,
training provided to staff, and type of facility). Data
collection occurred from October 10 through November
10, 2014.
The survey instrument used in this study was form A of
the Frommelt Attitude Toward Care of the Dying Scale
(FATCOD). The 30-item questionnaire uses a 5-point
Likert scale to indicate respondents’ beliefs/attitudes and
comfort/confidence in the provision of care for dying
patients and their families. 18 The instrument consists of an
equal number of positively and negatively worded state-
ments, with response options of strongly disagree, disagree,
uncertain, agree, and strongly agree. Positive items are
scored 1 (strongly disagree) to 5 (strongly agree); scores are
reversed for negative items. Possible scores can range from
30 to 150. A higher score indicates a more positive attitude
toward caring for this patient population. The reliability of
the FATCOD has been established using a test-retest
method with a sample of 18 oncology nurses, with a
computed Pearson coefficient of 0.94. 18 Additional
measures of the content validity index were computed at
1.00, with an inter-rater agreement of 1.00. 19
Participant Recruitment
For the survey arm of the study, a sample of English-
speaking emergency nurses (N = 1,879) aged 18 years or
older was recruited by an e-mail sent to all members of the
Emergency Nurses Association (ENA). The link to the
survey was also posted on the organizational Web site as well
as via social media sites (ie, Facebook, LinkedIn, and
Twitter) for the duration of the data collection period.
Three reminders were sent by e-mail to facilitate a large,
representative sample of emergency nurses who were
working in United States emergency departments. This
was a convenience sample, the use of which was to provide
information about the attitudes, beliefs, and educational
September 2015 VOLUME 41 • ISSUE 5
Wolf et al/RESEARCH
and resource needs of a specific group (emergency nurses)
managing a specific population (ED EOL patients).
Data Analysis
Survey data were exported to an SPSS database (IBM,
Armonk, NY), and descriptive analysis was performed. To
determine any statistically significant differences across
individual and facility demographic groups, additional
exploratory analysis was performed, including a comparison
of the mean FATCOD scores.
QUALITATIVE
Focus Group Interviews
Focus group data were collected in two 1-hour sessions
conducted at the 2014 ENA annual conference. The
purpose of the focus group sessions was to (1) identify
challenges and facilitators to safe effective care of the ED
EOL patient and (2) broaden understanding and explana-
tion of survey results. A semistructured interview consisted
of the following questions, which were developed in
consultation with an advisory council composed of 7
emergency nursing experts:
1.What are your thoughts and feelings about taking care
of ED EOL patients?
2.What are educational content needs for the care of ED
EOL patients?
3.What are barriers to safe and effective care for ED
EOL patients?
4.What resources are available to you as you care for ED
EOL patients?
Participant Recruitment
Focus group participants (N = 17) consisted of English-
speaking nurses aged 18 years or older who were working in
an emergency department at the time of the study.
Participants were recruited by an e-mail that was sent to
emergency nurses who were registered to attend ENA’s
2014 annual conference. Multiple recruitment and remind-
er e-mails were sent before the conference, and enrolled
participants were asked to complete a brief demographic
questionnaire before their focus group attendance.
Data Analysis
The focus groups were facilitated by the principal
investigator and a second researcher who took field notes
and audio recordings of the two 1-hour sessions. 20 Audio
recordings were transcribed in their entirety, and the
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RESEARCH/Wolf et al
transcript was analyzed for themes using constant comparison
and open coding of meaning units. 20 Transcripts were
reviewed by 4 members of the research team using a reiterative
process to identify meaning units that were grouped together
into codes and then further grouped into main categories and
themes. Three separate reviews of the coding process were
completed, until all team members agreed on emerging themes.
Results
Our survey sample consisted of a fairly homogeneous group of
emergency nurses who had consistently high mean FATCOD
scores (Table 1). Therefore descriptive analysis was deemed
sufficient to describe the results. Although we hypothesized that
there might be more variation in nurses’ beliefs/attitudes, a
comparison of mean values showed no significant differences by
category of individual (eg, age, gender, and years of experience) or
facility (eg, urban/rural, private/public, and small/large) demo-
graphic characteristics. As a result, analysis of the qualitative data was
prioritized to further explain and contextualize our study findings.
SURVEY FINDINGS
The 1,879 respondents who completed the survey provided
personal and institutional demographic data. The respondents
(N = 1,879) were from all 50 states (96.0%); Washington, DC
(0.2%); overseas US military bases (0.1%); and countries
outside the US (3.7%). The mean score on the FATCOD (n =
1,795) was 131 (SD, 10), with minimum and maximum scores
of 57 and 150, respectively; a mode of 132; and a median score
of 142. Because some respondents did not answer all of the 30
items on the FATCOD, these descriptive statistics are based on
data from respondents who completed the entire FATCOD
(range, 1,869-1,877 participants; Table 1). Overall, these
results indicate that this sample had positive beliefs/attitudes
about providing EOL care. Respondents’ nursing education
and experience with EOL care are described in Table 2.
FOCUS GROUP FINDINGS
A total of 17 nurses participated in 2 focus groups, with a
mean of 18.9 years of experience in emergency nursing (SD,
11.8 years). The focus group participants mainly worked in
general emergency departments (82.4%), in urban areas
(64.7%), and in hospitals with 40,001 to 75,000 annual
ED patient visits (47.0%). The nurses came from 6
Midwestern states (35.4%), 5 Eastern states (29.5%), 1
Southern state (11.8%), and 1 location outside the US
(5.9%). Focus group participants were asked to review the
findings and provide any feedback or clarifications, and 11
of 17 responded, stating that they agreed with the findings.
e26 JOURNAL OF EMERGENCY NURSING
Analysis of the focus group transcripts uncovered 9
themes that reflected concerns around comfort and challenges
with providing EOL care, as well as appropriate education
and resources to do it well. These initial themes were
described by the 4 members of the research team, reviewed by
7 emergency nursing experts, and then further analyzed for
completeness and illustration of the survey findings.
KNOWLEDGE AND SKILLS
Our participants reported high levels of comfort and confidence
with the technical and logistic aspects of EOL patient care; as one
respondent stated, “We know what to do and how to do it.” Yet,
they were cognizant that there are deficits and differences in learning
and applying the technical skills of emergency nursing compared
with those required for provision of EOL care. They talked about
the necessary skills for more holistic and comprehensive care, which
were seen partially as a function of nurses’ exposure to and ability to
manage the entire experience of the dying process.
I mean all of us as nurses are compassionate but not all
of us can speak to families the same—so I think there’s a
knowledge deficit . . . and I don’t mean to offend anybody,
but I don’t think that all nurses are very holistic in their
care of the patient. . . . I think some of the newer nurses are
very didactic-oriented, you know.—N2 (manager)
You know, we teach nurses . . . how to do tasks, but tasks
are not in this end-of-life. You have to literally pull out your
mind, body and soul and give it everything you have to the
patient and his family, and is that something that you can
truly teach?—N1 (certified nurse educator [CNE])
TABLE 1
Nurses’ education and experience in end-of-life care
n (%)
Education on death and dying (N = 1,879)
I took a course in death and dying 677 (36.0)
previously.
I did not take a specific course on death 980 (52.2)
and dying, but material on the subject
was included in other course.
No information dealing with death and 222 (11.8)
dying was previously presented to me.
Experience in dealing with terminally ill
persons (N = 1,879)
I have cared for terminally ill persons 1,811 (96.4)
and their family members previously.
I have had no experience caring for 68 (3.6)
terminally ill persons and their family
members previously.
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TABLE 2
Frommelt Attitude Toward Care of the Dying Scale (FATCOD) form A: Participants’ responses
Statement Agreement Level
SD D U A SA
1. Giving nursing care to the dying person is a worthwhile learning experience. (n = 1,877) 0.4% 0.4% 2.2% 27.5% 69.5%
2. Death is not the worst thing that can happen to a person. (n = 1,876) 2.9% 3.1% 4.5% 28.1% 61.5%
3. I would be uncomfortable talking about impending death with the dying person. (n = 1,875) 37.5% 39.3% 8.6% 10.9% 3.7%
4. Nursing care for the patient’s family should continue throughout 1.5% 2.4% 7.5% 31.9% 56.7%
the period of grief and bereavement. (n = 1,872)
5. I would not want to be assigned to care for a dying person. (n = 1,874) 56.0% 32.9% 5.8% 3.8% 1.5%
6. The nurse should not be the one to talk about death with the dying person. (n = 1,876) 41.7% 36.1% 12.8% 5.5% 3.8%
7. The length of time required to give nursing care to a dying person 37.0% 41.8% 11.4% 7.8% 2.0%
would frustrate me. (n = 1,874)
8. I would be upset when the dying person I was caring for gave up hope 43.1% 41.9% 9.9% 4.0% 1.1%
of getting better. (n = 1,873)
9. It is difficult to form a close relationship with the family of the dying person. (n = 1,875) 45.4% 41.0% 6.4% 5.5% 1.6%
10. There are times when death is welcomed by the dying person. (n = 1,874) 3.0% 0.7% 1.0% 29.3% 65.8%
11. When a patient asks, "Nurse, am I dying?,” I think it is best to 53.9% 39.5% 4.3% 1.3% 1.0%
change the subject to something cheerful. (n = 1,875)
12. The family should be involved in the physical care of the dying person. (n = 1,870) 1.6% 2.9% 16.7% 41.4% 37.4%
13. I would hope the person I’m caring for dies when I am not present. (n = 1,872) 37.1% 42.3% 15.0% 4.3% 1.3%
14. I am afraid to become friends with a dying person. (n = 1,873) 49.0% 42.0% 5.2% 2.9% 0.9%
15. I would feel like running away when the person actually died. (n = 1,874) 61.7% 32.8% 3.3% 1.4% 0.8%
16. Families need emotional support to accept the behavior changes of 1.0% 0.8% 1.1% 35.2% 61.8%
the dying person. (n = 1,870)
17. As a patient nears death, the nurse should withdraw from his/her 64.0% 31.0% 2.8% 0.9% 1.3%
involvement with the patient. (n = 1,869)
18. Families should be concerned about helping their dying member make 2.1% 3.5% 11.0% 39.8% 43.6%
the best of his/her remaining life. (n = 1,869)
19. The dying person should not be allowed to make decisions about his/her 81.7% 11.9% 0.3% 0.9% 5.2%
physical care. (n = 1,874)
20. Families should maintain as normal an environment as possible for their 1.4% 5.1% 15.8% 43.0% 34.6%
dying member. (n = 1,875)
21. It is beneficial for the dying person to verbalize his/her feelings. (n = 1,873) 1.1% 0.6% 2.5% 25.3% 70.5%
22. Nursing care should extend to the family of the dying person. (n = 1,873) 0.8% 0.6% 2.7% 31.4% 64.5%
23. Nurses should permit dying persons to have flexible visiting schedules. (n = 1,874) 1.2% 0.2% 0.5% 14.5% 83.7%
24. The dying person and his/her family should be the in-charge decision makers. (n = 1,871) 0.7% 1.1% 6.7% 33.5% 58.0%
25. Addiction to pain-relieving medication should not be a concern when 4.1% 1.9% 2.9% 18.1% 73.0%
dealing with a dying person. (n = 1,874)
26. I would be uncomfortable if I entered the room of a terminally ill person and 37.8% 40.2% 10.0% 8.8% 3.2%
found him/her crying. (n = 1,871)
27. Dying persons should be given honest answers about their condition. (n = 1,872) 1.4% 0.6% 1.0% 23.9% 73.1%
28. Educating families about death and dying is not a nursing responsibility. (n = 1,866) 58.1% 34.1% 3.8% 2.5% 1.4%
29. Family members who stay close to a dying person often interfere with the 40.9% 41.7% 10.9% 5.1% 1.4%
professional’s job with the patient. (n = 1,870)
30. It is possible for nurses to help patients prepare for death. (n = 1,867) 1.3% 1.0% 2.0% 36.2% 59.5%

The total number of respondents was 1,879; the total number of respondents who completed all questions on the FATCOD score was 1,795; and the range in the number of respondents for all 30 items varied from 1,867 to 1,877.
A, agree; D, disagree; SA, strongly agree; SD, strongly disagree; U, uncertain.

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RESEARCH/Wolf et al
EDUCATION
Participants saw the value of more integrated EOL content in
nursing education, as well as the need for clear practice
guidelines to improve EOL nursing skills and patient care.
[They have] their internship and they go places really
where they need to be focusing on the basics, the
foundations, and to me, end of life is a basic foundation
because it’s going to happen whether you’re working on
a pediatric PIC-U unit [pediatric intensive care unit],
ER [emergency room] unit, medical unit—you need to
know how to experience that.—N2 (manager)
They [the nurses] do want policies and guidelines
that will back them up in the care that they provide. . . .
They do not even know there is a palliative care nurse;
they do not know what numbers to reach them or
the physician. They were not aware of any guidelines
or policies, and if they were available, did they cover the nurse
that was in the emergency department?—N1 (CNE)
ATTITUDES AND BELIEFS ABOUT DEATH AND DYING
Participants also were aware of how cultural views, clinician
and societal attitudes/beliefs, and personal judgments about
death and dying affect the experience of EOL care in the
ED setting.
There’s something about a stigma—about dying in
the ER. As far as a kid dying in the ER, I don’t know, I
think that maybe someone who doesn’t work in the
ER—it looks like the ER didn’t do their job and they
died in the ER kind of thing, if that makes sense.
There’s that stigma.—N9 (charge nurse)
You know, during codes, everybody is in the room;
everybody is doing a job. But, as far as end-of-life care, it’s
almost like a non-verbal, “Well, they’re done—we’re done
with that—there’s nothing more we can do; let’s go do
something for somebody we can do something for.” And
in our department, we don’t really have an allowance for
that nurse spending time with the family, with the patient,
doing the comforting.—N13 (staff nurse)
[T]he patients that have decided that they really
want to continue to fight—I’ve changed my thought
about where I felt that “why are they doing [that] . . . ?”
Really, I’m just judgmental; I guess that’s the long and
short of it.—N12 (case manager)
APPROPRIATENESS OF SETTING
Our participants were in agreement that the chaos, noise,
and unpredictability typical to most emergency depart-
ments make this setting “the wrong place to die.” For our
e28 JOURNAL OF EMERGENCY NURSING
participants, the arrival of an EOL patient in the emergency
department was an “indicator of system failure,” meaning
that the supports for that patient in the community had
failed and that the patient and family needs were not being
met in the way the nurses believed that they should be.
It’s that it’s an inappropriate place to die. It’s not
quiet, it’s not private, it’s not calm, it’s not peaceful, it’s
not dim lights. . . . It’s just the wrong place to be.—N7
(staff nurse)
[Y]ou see the emergency end-of-life patients in the
ER; they either have crisis or they [have] inadequate
symptom management, inadequate support—something
[is] going wrong [because] they showed up here.—N8
(nurse practitioner [NP])
But then they have that horrible pull that they will
not be able to provide the kind of supportive palliative
care that they know that patient and family deserve
because of where they are.—N3 (CNE)
And it is a systems failure. Not one bed in this hospital
can accommodate this one patient? But the way that we’re
conditioned to think is, “This is not the most critical
patient in the entire hospital.” We think, “Who is the
most critical patient in the ED? It’s not this one.” And so
they get lost. And we’re compassionate.—N1 (CNE)
RESOURCE LIMITATIONS
Connected to the chaos and noise of the ED environment
was the issue of a lack of resources in the emergency
department that were usually available in other areas of the
hospital. Participants believed that patients needed and
deserved these resources (time, space, appropriate interdis-
ciplinary personnel) regardless of location or time of day,
recognizing that “resources are a systems problem, not an
ED problem”:
So, when you come in and you’re in that situation,
you may feel neglected because the reality is we’re
always short staffed and someone who’s in acute need
right then will take priority over someone who has
come in with end-of-life issues. That’s just reality.
Which is sad.—N17 (staff nurse)
Our social services are not available at night. I mean
we can call them, but they will not respond to the ED
at night, which I personally find distressing as a
nurse.—N13 (staff nurse)
And I think that’s the biggest issue—the time, the
management, the privacy, the space . . . and I don’t
know how you make that happen. All the education in
the world is not going to necessarily bring those
resources.—N6 (clinical nurse specialist)
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Sometimes, to move them to a quieter place would
be more traumatic than actually leaving them where
they’re at. There’s more than just looking at the room
and looking at the family because everything else that’s
going on. Who are you going to traumatize more—the
patient’s family or the families that are in your
department? There are so many variables to look
at.—N4 (charge nurse)
EMOTIONAL INTELLIGENCE
Our participants reported a profound dissonance between
the nature of emergency care and the nature of EOL care as
they believe it should be provided. Some participants were
very clear about why they chose emergency care, speaking to
a desire for less emotional bonding with their patients and
recognizing the prolonged, intense emotional component of
providing good EOL care to patients and families. They also
spoke to the difficulty of the mental and emotional switch
from “fixing” to “providing comfort” and the focus on time
management where the expectation for emergency nursing
care is to “stabilize and move.”
I don’t want to bond with my families and patients
to the extent to where I feel like I lost myself. I don’t
want that. Yes, I bond with my patients in the ER for
that short time, but I don’t need to know their whole
history and their whole life story. Yes, I cry when I go
home when I have a child die that day, but I don’t miss
that other, you know, primary care nursing where
you’ve had a child for six weeks and you know his
family like the back of your hand. . . . I can’t do
that.—N9 (charge nurse)
You get them in, you get them out, and they
[management] don’t provide the nurse any opportunity
really to sit back and be able to spend time with that
family because we have a huge patient ratio and it does
not matter about acuity; it’s just—it’s volume—that’s
how they see it, volume. The patient is dead, that’s it,
they’re done.—N17 (staff nurse)
We’re going to do everything we possibly can to save
your life and then we’re going to move you to somebody
else that can care for you then, and I did my job. I
stabilized you and got you to where you need to be, and
now I’m going to move on to whomever else needs me.—N16
(charge nurse)
Also noted by our participants was the stress and related
post-traumatic stress disorder symptoms of providing care
to patients with life-threatening illnesses and injuries, not
once or twice a week or month but constantly, on every
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Wolf et al/RESEARCH
shift. The need to be emotionally protective of oneself and
one’s colleagues was a recurrent theme:
And I know at least in our area, when we do have a
death and a nurse is taking care of that patient and their
family, we try to shift the heavier part of everything
away from the rest of the back area. We don’t want
them feeling like they have to come out sooner than
they have to.—N4 (charge nurse)
There’s a lot more under that surface. But I think
because it’s so busy, you don’t have time to address
your feelings.—N17 (staff nurse)
Well, because when you do that [emote], you open
yourself up, you become vulnerable. When you
sometimes put this up, that’s going to touch you at
home; you’re sitting there crying or pounding the walls
or whatever you might need to do to release that
stress.—N16 (charge nurse)
[H]umor—we can laugh at things that nobody else
can and people don’t understand that’s where we get it
from, it’s our . . . it’s how we deal.—N9 (charge nurse)
MANAGEMENT OF PATIENT AND FAMILY ISSUES
Although our participants recognized the emotionally
focused care needs of EOL patients and families, they also
spoke about how they were willing to provide that care
when time permitted and they wanted to do it well because
of the lasting impact on the families of patients who died in
their emergency departments.
We’ve dehumanized people. . . . We’ve seen the
living and dead within the ER and I guess that’s where
my struggle is. . . . I do take the time to say, “Who can I
call for you? Do you have a pastor you need? Are there
family members that you want here? What can I do for
you right now?” I mean, even though it doesn’t make it
better, even though it doesn’t change the circumstances
. . . it takes literally maybe 15 minutes of your
time.—N17 (staff nurse)
Well, the lady . . . her husband had a cardiac arrest
and we weren’t able to get him back; she said, “What do
I do, what do I do, what do I do?” And she was rocking
and just. . . . I said, “Honey, you’re going to breathe;
right now that’s all you need to do—just breathe.”—
N13 (staff nurse)
However, it is interesting to see that these family
members that come back years later and tell you
their experience—the one thing they all say
consistently, over and over again, is, “We just
wanted somebody to be responsible for us. Meaning
to tell us what to do, where to go, what to say, what
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RESEARCH/Wolf et al
do we do now. We just want somebody to hold our
hand.”—N9 (charge nurse)
DESIRE TO HONOR PATIENT AND FAMILY WISHES
Another recurrent, strong theme was the desire to honor
patient and family wishes. One participant recalled that,
“When faced with imminent death, families and patients
change their minds.” This was echoed by others who voiced
frustration with the lack of information and confusion
about patients’ directives and patients’/families’ uncertainty
about treatment decisions, especially in the midst of a crisis.
The families are fine if the patient dies in their sleep,
but the patient can’t die from being sick, being short of
breath, being end-stage heart failure, being anything
that somebody in the family perceives could be
fixed.—N3 (CNE)
Those patients who do come in as a DNR [do not
resuscitate], and we don’t know, we don’t have the
paperwork, we have nothing, the patient’s family is not
available, and they start trickling in and start
implementing things; orders start getting put in and
there’s no beds available in the hospital.—N1 (CNE)
We’re pretty good at end-of-life issues when people
already have their DNRs in order. We have social workers
that come down, if it’s a sudden unexpected death, there’s
the killer for everybody and that’s hard to deal with
because you have family there in crisis and all of a sudden
they’re not hearing anything.—N17 (staff nurse)
COORDINATED CARE MODELS
There was a small subset of participants who described
improvements to better coordinate EOL care in their
facilities that the other participants found encouraging and
exemplary. These nurses described closely aligned interdis-
ciplinary teams of hospice care/palliative care physicians and
nurses, social workers, and administrators who worked to
minimize the time spent in the emergency department and
to facilitate transfers to more appropriate settings for these
patients at EOL.
We have a group of younger physicians in our
emergency department that are very proactive in talking
to the families . . . if they know the patient and they’ve
been coming frequently, and frequently for the same
type of stuff, they’ll actually discuss hospice care. And
we’re lucky enough that we have a hospice unit in our
facility . . . so they’re very good about coming down
and talking to the families . . . and oftentimes, those
types of patients, we actually can get them [to
hospice].—N11 (trauma educator)
e30 JOURNAL OF EMERGENCY NURSING
We’re going to be implementing a palliative
screening tool for the oncology ED, but then we hope
to spread it to the main emergency room . . . so that,
you know, the people who have those advanced care
plans—end-of-life plans—in place that can be imple-
mented more quickly instead of being “save the life”;
well, let’s preserve that end-of-life experience.—N14
(staff nurse)
Discussion
Dealing with death and dying is a common experience for
emergency nurses, yet the delivery of EOL care in ED
settings is an understudied area of research. 1 We conducted
an exploratory mixed-methods study for the purpose of
identifying challenges and facilitators to EOL care that
included emergency nurses’ attitudes, beliefs, and educa-
tional and resource needs. Using the FATCOD survey, we
found that nurses had a high level of consistently positive
attitudes and beliefs toward caring for dying patients and
their families or loved ones, with no significant differences
across individual or facility demographic groups. Although
this is a demographically diverse sample of emergency
nurses, all respondents were members of the ENA, and
thus, they represent a fairly homogeneous professional
group with substantial experience in emergency care (85%
aged N 35 years, with an average of 15.5 years of ED
experience). Nearly all respondents (96.4%) reported
having cared for terminally ill patients and their families
(96.4%), and a large majority (88.2%) had also received
some EOL education.
Other researchers have also suggested that nurses’ level
of exposure and education regarding death and dying may
play a role in their perceptions of EOL care. 8,14 In an
evaluation of an EOL educational intervention, Bailey and
Hewison 14 found that a 1-day workshop resulted in a
statistically significant increase in nursing students’ attitudes
as measured by pre-post FATCOD scores. The greatest
increase in scores occurred among students who reported
having had some previous education on death and dying.
A similar educational effect may have influenced the
self-reported FATCOD scores in our sample of highly
experienced emergency nurses. The results of other studies
also showed improvements in FATCOD pre-post measures
of nursing students’ attitudes/beliefs toward care of the
dying. 11,21,22 However, in a single-state survey (N = 567),
Schlairet 12 found that nurses had notable deficiencies in
knowledge and competency ratings for 23 EOL content
areas, despite their positive attitudes toward EOL care. As
the author concluded, subjective ratings of attitudes/beliefs
VOLUME 41 • ISSUE 5 September 2015

do not necessarily reflect actual skills and abilities. Rather,
self-reports of positive attitudes/beliefs might be indicative
of nurses’ desire to deliver quality EOL care, whether or not
they are competent to do so.
Given the high positivity in FATCOD scores and
subsequent limitations for interpreting our survey findings,
the qualitative data were prioritized to further explain and
contextualize the study results. Focus group participants
were demographically similar to survey respondents, all of
whom had experience caring for terminally ill or dying
patients and their families. There was strong agreement
within this group that emergency nurses are confident and
comfortable with technical aspects of EOL care; yet, they
also recognized the complexities of providing quality care to
terminally ill and dying patients in the emergency setting.
As one participant poignantly stated, “Death is an
experience, not an event.” Participants talked about how
familiarity with and exposure to the entire experience of the
dying process may contribute to nurses’ ability to provide
quality EOL care. Moreover, they clearly recognized that
the task-oriented and life-saving aspects of emergency care
often result in an unintended dismissal of patients’ and
families’ needs for EOL care, especially when there are no
treatment options remaining.
Nurses discussed the environmental conditions of
limited time, space, and resources that also affected their
ability to deliver the level of EOL care required. They
expressed frustration with the conflict between the usual
fast-paced, chaotic, and unpredictable ED environment and
the conditions of quiet, privacy, and therapeutic calm
required to meet the EOL needs of patients and families.
Participants highlighted other components of the mismatch
between emergency and EOL care, emphasizing the high
levels of emotional investment required to manage patient
and family EOL expectations, as well as the gaps in
resources not typically available in the emergency depart-
ment. Like other studies of emergency clinicians’ experience
with EOL care, 6,8,23 this group of nurses expressed concerns
that the emergency department was not an appropriate
place for the terminally ill or dying patient. They described a
prevailing culture in which there is a “stigma against dying
in the ER” and a focus on efforts to save lives and to “fix,
stabilize, and transfer” patients to another area where EOL
care can and should be provided. This finding is consistent
with the description of Bailey et al 5 of 2 distinct trajectories
of care: the spectacular death in which patients are treated
with the heroic measures consistent with emergency care
providers’ “ability to restore function and save life” and the
subtacular death in which patients and families are isolated
and receive less attentive care based on the patients’ “high
potential for death and low or no potential for successful
September 2015 VOLUME 41 • ISSUE 5
Wolf et al/RESEARCH
intervention.” Our nurses described similar practices in
which patients were “left in the hallway to die” or “left
waiting for placement” because of competing demands and
practices; as expressed by one nurse: “They’re done—we’re
done with that—there’s nothing more we can do; let’s go do
something for somebody we can do something for.”
Our focus group participants described how the ability
to manage one’s emotional response influenced nurses’
interactions with patients and families, with a set of
reactions ranging from being highly vulnerable to utterly
avoiding the death experience. Nurses talked about how
they believed that “The ED is the place where we fix people
and move on, not bond”; yet they felt “pulled in many
directions” and went home “crying or pounding the walls.”
One nurse explained it this way: “I think it’s . . . part of it is
just personality, and that acknowledgment or that ability to
maybe deal with those raw emotions of grief and the
unknown.” Similar research has pointed out how these
variations in emotive responses can affect practitioners’
management of the death and dying experience. In one
study, third-year medical students reported being aware that
they were becoming desensitized to the human dimension
of care and expressed a desire to learn to contain their
emotions to better serve their patients. 24 The management
of emotive aspects of care and the therapeutic nurse-patient
relationship are central components of a 3-stage model for
developing expertise in EOL care that evolved from the
work of Bailey et al. 7 The members of our focus groups
described situations in which they were able to respond
compassionately (eg, using gentle touch to comfort) and to
feel empowered to advocate for their patients (eg, securing
private, quiet space). Our study findings support previous
literature wherein such capabilities have been cited as
learned “emotional competencies” 25,26 that are fundamen-
tal to “developing expertise” and “overcoming adversity” 7 in
nursing education and practice. However, authors of an
integrated literature review concluded that further research is
needed to address gaps in knowledge related to emotional
intelligence and nursing education, practice, and leadership. 27
In addition, some studies have shown variable results
regarding the impact of educational EOL interventions, and
those investigators recommended more rigorous evaluation
of EOL content in nursing curricula 12,13—including
content specific to the development of emotional intelli-
gence 14,27—that would help to prepare emergency nurses
to care for dying patients and the bereaved. In discussions
regarding coping skills and stress management, some of our
participants described aspects of quality EOL care such as
“bereavement counseling,” “compassionate care,” and
“holistic management” of patient and family needs. These
results suggest that some emergency nurses recognize and
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RESEARCH/Wolf et al
desire to practice emotional intelligence competencies,
whether or not they are able to implement them in their work
setting. The role of emotional intelligence in emergency nursing
EOL education and practice requires further exploration.
Limitations
The generalizability of our study findings is limited because
both our survey and focus group participants were
self-selecting groups of emergency nurses who reported
their subjective experience and beliefs regarding EOL
emergency care. Similarly, a small subset of nurses who
did not answer all 30 items of the FATCOD survey (4.5%)
were eliminated from analysis of FATCOD scores (Table 2).
Thus we do not know why those individuals chose not to
answer certain questions or how their responses might differ
from the rest of our sample. In addition, the consistency in
highly positive attitudes among this group may be a reflection
of desirability to provide good EOL care, rather than an
indicator of actual practice.
Implications for Emergency Nursing
Focus group participants expressed a common desire to
provide support for patients and families at the EOL but
reported a lack of protocols and guidelines, especially for
managing acutely ill dying patients. Nurses described the
emotional toll and burnout that can result from the inability
to provide quality EOL care, and they were also able to
identify specific competencies that they believed would help
manage their stress and improve patient/family care. These
suggestions included bereavement counseling, compassionate
care, and holistic management of patients and family needs.
Several participants shared alternative care models, including
in-hospital hospice and EOL/palliative care teams, EOL/
palliative care training for ED staff, a 24-hour EOL hotline for
caregivers, and expansion of chaplain or other social services to
assist with the EOL transition (eg, completion of the death
certificate, funeral arrangements, and disposition of the
body). Other recommendations included integration of death
and dying exercises into nursing curricula, respect for spiritual
and cultural differences, and supportive strategies (eg,
debriefings after EOL events) to help staff develop coping
and stress management skills.
Conclusions
This mixed-methods study indicates that emergency nurses
are comfortable with providing care, have positive attitudes
e32 JOURNAL OF EMERGENCY NURSING
toward the dying, and believe patients and families deserve
to have a dignified EOL experience. However, they
recognized that this was not always achievable—or even
appropriate to their defined role—within the constraints of
the emergency care setting. They described a mismatch
between the life-saving nature of emergency care and the
more emotionally demanding nature of EOL care—one
that often resulted in arbitrary decisions to prioritize one
patient’s needs over another’s. Significant challenges to
providing EOL emergency care included limited time and
space; gaps in resources and services; inadequate staff
education and preparation; and the heavy emotional burden
on nurses, patients, and families. More research is needed to
better understand the relationship among emergency
nurses’ positive attitudes toward caring for the dying and
bereaved, their exposure to EOL education, and the actual
practice competencies that could improve the EOL
experience for nurses, patients, and families in the
emergency department.
Acknowledgment
We acknowledge Leslie Gates for her assistance with this study.
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