End-of-Life Care II: Rapid Response for Dying Patients Without NFR Orders

Dying is common in acute care hospitals, and approximately one-third of hospitalised patients will encounter the rapid response system (RRS) in the last days of their life. A triage approach at RRS calls can be used to identify patients with end-of-life care (EOLC) needs. The challenge remains in patients with uncertainty around EOLC, such as patients without documentation of limitations of medical treatment (LOMT), where there is lack of consensus between medical teams and patients and next of kin, uncertainty in prognosis or evidence of advanced comorbidity and/or low-level pre-morbid function. Early recognition of dying, advanced care planning (ACP) and goals of care (GOC) documentation is important to prepare clinicians, patients and their next of kin for events of deterioration. Patient preparedness for end of life is important to reduce non-beneficial investigations and treatments and deliver high-quality, patient-centred care. RRS calls with EOLC issues represent a moral and ethical challenge, particular for junior staff and where there is uncertainty about prognosis and treatment plans. This chapter outlines the epidemiology of EOLC RRS calls, an approach to their triage, issues around moral and ethical challenges and an approach to their management.