INTRODUCTION

Death is an inevitable part of the human experience, beginning from the moment of birth. Despite advances in modern medicine focusing on life prolongation, the emphasis on such treatments can complicate the process of experiencing a dignified death. Terminally ill patients often endure fear and anxiety about treatment failure rather than embracing a natural acceptance of death, making it difficult to express their treatment preferences [1].

Although hospice and palliative care have evolved over the last half-century in Korea to improve the quality of end-of-life (EOL) care [2], a unique challenge exists in emergency departments (EDs). These departments frequently become the final destination for critically ill patients seeking urgent symptom management despite being designed for rapid assessment and life-saving interventions rather than EOL care [3]. This challenge has become particularly pressing in South Korea because of the rapidly aging population. EDs across the country face considerable challenges in EOL care. Recent statistics from 2016~2019 showed that 45.6% of ED deaths were related to advanced cancer, followed by organ failure (29.1%), sudden death (13.6%), and chronic frailty (11.7%)[4]. Among the 36,538,486 ED visits during this period, 34,086 deaths were recorded [4], highlighting the major burden on EDs in managing EOL care.

However, the typical ED environment, designed for rapid assessment, treatment, and life-saving interventions, is often ill-suited for delivering high-quality EOL care [5,6]. The fundamental principles of emergency caremaximizing patient visibility, delivering prompt treatment, minimizing complications, and focusing on life-saving measures-create an inadequately equipped environment to address the nuanced needs of EOL care [5,6].

Statistics reveal the urgency of this issue. In 2022, 47.6% of patients who died in EDs arrived in cardiac arrest and underwent cardiopulmonary resuscitation (CPR) before death, whereas 22.4% were dead on arrival [7]. These data confirm that EDs are often the final stop for many terminally ill patients; however, they remain geared toward aggressive and invasive interventions rather than the comfort and dignity of EOL care [8-10]. Furthermore, there is a persistent perception within EDs that death, particularly in emergencies, equates to professional failure [9]. This mindset poses additional obstacles to providing compassionate EOL care as it prioritizes rapid treatment and invasive procedures over patient comfort and dignity [11].

Previous research has predominantly focused on EOL care in nursing homes and intensive care units, leaving a gap in understanding how these challenges manifest in emergency settings [3]. Although international studies such as Mughal and Evans’s study [12] have reviewed ED nurses’ experiences with EOL care, the limited scope and different contexts, including the unique environment of Korean EDs, indicate a need for further exploration.

Given these challenges, qualitative research is essential to gain an in-depth understanding of the real-world problems faced by ED staff providing EOL care. A qualitative approach allows for exploring how individuals interpret their experiences and construct meaning, thereby providing valuable insights into the complexities of patient care in high-pressure environments. Thematic analysis is advantageous for integrating individual data, identifying patterns, and developing concepts within a constructivist framework [13].

Therefore, in this study, we aimed to explore the experiences of ED nurses in delivering EOL care through a thematic analysis. By investigating the difficulties encountered, we seek to provide the foundational data necessary for enhancing the quality of EOL care in emergency settings.

METHODS

1. Research Design

In this qualitative descriptive study, we aimed to explore the experiences of ED nurses in providing EOL care. Individual in-depth interviews were conducted using a semi-structured questionnaire to capture the participants’ perspectives. Data were then thematically analyzed following the approach of Braun and Clarke [13], allowing for the extraction of key themes and subthemes related to EOL care in the ED.

2. Participants

The study was conducted at the ED of G University Hospital in J city, G province. The participants were recruited through posted notices in the emergency medical center. Using purposive sampling, we recruited nurses with at least 1 year of EOL experience in the ED. This criterion was chosen to ensure the nurses had sufficient experience to provide rich data (Table 1). Recruitment occurred from April 5, 2024, to June 5, 2024, and continued until data saturation was reached with 12 participants.

3. Data Collection

1) Recruitment

Recruitment and data collection occurred from April 5, 2024, to June 5, 2024. A notice was posted at the emergency medical center of G University Hospital in G city, J province, inviting nurses to participate. Using purposive sampling [14], we recruited nurses who had at least 1 year of experience in providing EOL care in the ED, could articulate their experiences clearly, and voluntarily agreed to participate after understanding the purpose of the study.

The final sample size of 12 participants was determined through data saturation, a key concept in qualitative research [15]. Recent systematic reviews suggest that saturation in qualitative interviews typically occurs between 9 and 17 participants [16]. Saturation was reached when no new themes or insights emerged from the interviews, and the existing themes showed sufficient depth and variation. We carefully monitored the data collection process through iterative analysis [17].

2) In-depth interviews

Interviews were conducted individually in quiet and comfortable locations chosen by the participants, such as a hospital meeting room or private cafe. A semi-structured interview guide facilitated the discussions. The researcher began with casual conversations on daily topics to create a relaxed atmosphere before delving into the main questions. The main interview questions included: “Can you describe your experiences caring for EOL patients in the ED?” and “What challenges have you faced when providing such care?” (Table 2).

With the participants’ consent, interviews were audio- recorded using a tablet and smartphone. Nonverbal expressions such as facial gestures and attitudes were noted to aid the analysis. The recorded interviews were transcribed verbatim and cross-checked to ensure accuracy.

4. Ethical Considerations

This study was approved by the Institutional Review Board of J city, G province’s tertiary hospital (IRB No. 2024-02-026-001). The participants were informed of the study’s purpose, procedures, and confidentiality measures. Written consent was obtained, ensuring the participants’ voluntary involvement and right to withdraw at any time without consequences. The data were anonymized, stored securely, and accessible only to the researcher.

5. Data Analysis

Data were transcribed using the Naver Clova Note application for accuracy, with cross-verification to maintain the integrity of the participants’ narratives.

Data were analyzed using Braun and Clarke’s [13] six-phase thematic analysis method:

6. Methodological Rigor

The reliability of this study was established through a systematic approach to ensure methodological rigor [18, 19]. The researcher’s qualifications included extensive training in qualitative methodology, completion of multiple qualitative research courses, and active participation in qualitative research workshops. Additionally, the researcher had previous experience conducting qualitative studies exploring nurses’ experiences with EOL care.

To ensure methodological rigor, we implemented multiple verification strategies aligned with established qualitative research standards [14,17]. The credibility of our findings was strengthened through regular peer debriefing sessions with three nursing professors with extensive qualitative research experience. We checked with the participants to verify the accuracy of our interpretations and maintained detailed field notes documenting contextual information and researcher reflections throughout the study period.

To establish dependability and confirmability, we maintained a comprehensive audit trail of all analytical decisions and a reflexive journal documenting potential biases and personal perspectives. Regular consultations were conducted with expert qualitative researchers to ensure the robustness of the analytical process. Furthermore, we enhanced the transferability of our findings by providing rich and thorough descriptions of the research context and participant characteristics, detailed documentation of the ED environment and care processes, and clear descriptions of the participant selection criteria and recruitment procedures [18].

RESULTS

1. General Characteristics of Participants

The study included 12 nurses from a tertiary hospital ED with at least 1 year of experience in EOL care. The participants’ ages ranged from 24 to 39 years, with an average age of 28.3. Among the participants, there were 11 females and 1 male. The participants had varied religious backgrounds: Atheism (six), Buddhism (three), Christianity (two), and Catholicism (one). Educational levels included four associate degree holders, six bachelor’s degree holders, and two with graduate-level education. Clinical experience ranged from 27 to 200 months (from 2 years 3 months to 16 years 8 months), averaging 87 months (7 years 3 months). ED-specific experience ranged from 27 to 132 months (2 years 3 months to 11 years), averaging 55 months (4 years 7 months) (Table 3).

2. Thematic Analysis of EOL Care in the ED

Five main themes were identified: Inadequate Environment for EOL Care, Impact of Life-Sustaining Treatment Decision Complexity, Managing Care Relationships in Physician-Limited Settings, Challenges in Protecting Pati-ents’ Rights, and Actualizing Compassionate EOL Care. Each theme encompasses specific subthemes, providing a detailed understanding of the complexities and challenges faced by ED nurses (Table 4).

Theme 1: Inadequate Environment for EOL Care

Nurses frequently encounter death in medical institutions, making environmental conditions crucial for providing appropriate EOL care. In EDs, the challenge of de-livering dignified EOL care is particularly pronounced, as these spaces are primarily designed for rapid interventions rather than supporting the emotional and spiritual needs of dying patients and their families.

Subtheme 1.1: Physical environment barriers for a dignified death

The ED’s physical layout and atmosphere create major obstacles to providing appropriate EOL care. Nurses struggle to maintain patient dignity and privacy while managing technical aspects of care. The lack of dedicated spaces for EOL care affects not only the patient’s experience but also the ability of healthcare providers to deliver comprehensive care.

The ED feels like a battlefield... so many things happening at once. It’s hard for patients and families to come to terms with death here. (P04)

Even during CPR, it’s all in the open. We can’t block out the noise; it’s simply not possible to create the environment necessary for a dignified farewell. (P08)

Sometimes we have to move patients between beds just to create some semblance of privacy, but it’s never enough. (P01)

Subtheme 1.2: Emotional restraint in a chaotic setting

The fast-paced ED environment creates a complex dynamic in which nurses must balance their professional responsibilities while managing the emotional burden of EOL care. This emotional strain is particularly important as they attempt to provide quality care for terminally ill patients in an environment primarily focused on acute care. Maintaining emotional composure while delivering EOL care requires specific competencies. Yet, the fastpaced nature of the ED often compromises nurses’ ability to provide the level of emotional support they wish to offer.

When someone passes away, we are told to quickly fill out forms and prepare for the next patient. There’s just no time for the family to say goodbye. (P12)

I felt so bad that I thought I was lucky to get the DNR [do-not-resuscitate] order quickly before handing it over. (P10)

We’re trained to save lives, but sometimes we need to step back and focus on providing comfort. Finding that balance in the ED is incredibly challenging. (P07)

The constant flow of new emergencies means we can’t give dying patients the time and attention they deserve. It’s emotionally draining for everyone involved. (P10)

Theme 2: Impact of Life-Sustaining Treatment Decision Complexity

ED nurses face considerable ethical challenges when navigating life-sustaining treatment decisions. This process creates intense moral distress as nurses attempt to balance medical necessities with cultural sensitivities while working within institutional constraints. The complexity is heightened by the need to make rapid decisions while ensuring ethical practices and maintaining family trust.

Subtheme 2.1: Complex dynamics of family decision-making

The intricate process of family decision-making regarding life-sustaining treatment creates ethical challenges for nurses. Nurses must navigate complex family dynamics while considering financial constraints, cultural expectations, and legal requirements often conflicting with immediate medical needs.

The patient's caregivers say they don't want to proceed with life-sustaining treatment because of financial reasons, but the patient themselves wants it. The patient wants to live, but it's just cruel that they can't get treatment because of money issues. I understand the situation, but it breaks my heart. Still, it's their family's story, and there's nothing I can do to intervene. (P09)

Sometimes families are torn between traditional values and modern medical options. The decisionmaking process becomes even more complicated when multiple family members are involved. (P03)

Subtheme 2.2: Compromised care quality in the decisionmaking process

The ethical complexity of life-sustaining treatment decisions greatly affects nurses’ ability to provide quality EOL care. When faced with challenging decision-making situations, nurses experience moral distress, which affects their clinical judgment and care delivery. This distress is particularly acute in emergency settings, where the pressure of rapid decision-making often conflicts with the need to maintain quality care. New palliative care legislation has added another layer of complexity to these ethical challenges, further affecting the quality of care.

I want to comfort my patient’s guardian when he sees a patient at the end of his life and cries asking if she is in pain, but I can’t because I have other patients to take care of. (P11)

Being pushed to make quick decisions about life-sustaining treatment compromises our ability to provide the level of care these patients deserve. (P06)

We often find ourselves having to choose between spending time with a dying patient and their family or attending to acute emergencies. There’s no right answer. (P05)

Theme 3: Managing Care Relationships in Physician- Limited Settings

ED nurses experience severe moral distress and role conflicts when physicians provide limited information and delegate EOL care responsibilities. This situation creates a complex dynamic in which nurses must balance their professional boundaries with families’ pressing need for information and support. The pressure to serve as the primary care presence while maintaining appropriate professional limitations creates unique challenges in the nurse-family relationship.

Subtheme 3.1: Navigating limited physician communication

When physicians provide minimal information, nurses find themselves in a delicate position of trying to enhance families’ understanding without overstepping professional boundaries. This creates a situation where nurses must carefully balance their roles as information facilitators while respecting the medical hierarchy. Nurses often become the default source of clarification and support, leading to substantial emotional and professional strain.

After the doctor’s brief visit, families look to us with so many unanswered questions. We’re left trying to fill in the gaps without overstepping our role. (P05)

Sometimes we see families struggling to understand the doctor’s brief explanation, but we have to be careful about how much we can clarify. (P08)

The hardest part is when we know more context that could help families understand, but we’re limited in what we can share. (P11)

Subtheme 3.2: Bearing the emotional weight of EOL care

Limited physician involvement in EOL care creates a situation in which nurses become the primary sources of emotional support and guidance for families. This expanded role requires nurses to provide comprehensive emotional and spiritual support while managing their emotional responses to challenging situations. The participants’ experiences highlighted the intense emotional labor involved in being the consistent presence for families during critical EOL decisions.

We become the primary emotional support for families when doctors are unavailable. It’s exhausting but necessary. (P10)

Families cling to us for guidance and comfort because we’re the ones consistently present. (P03)

The emotional labor is intense, we’re not just explaining care, we’re helping families process their grief. (P06)

Theme 4: Challenges in Protecting Patients' Rights

ED nurses experience profound moral distress when navigating the complex terrain of protecting patients’ rights during EOL care. Despite legal frameworks designed to protect patient autonomy, nurses frequently encounter situations where their roles as patient advocates conflict with institutional constraints and family dynamics.

Subtheme 4.1: Powerlessness in the face of silent patients

Nurses face ethical challenges when caring for unconscious patients during the DNR decision-making process. Their role as patient advocates becomes particularly complex when they must interpret nonverbal cues while respecting the decision-making authority of the families.

When patients are unconscious during DNR discussions, we’re torn between our duty to advocate for their presumed wishes and respecting family decisions. It’s an impossible ethical position. (P09)

We observe patients’ subtle responses to treatment and wonder if their wishes align with the decisions being made for them. As nurses, we feel responsible yet powerless to influence these critical choices. (P12)

Subtheme 4.2: Confusion from reversed decisions by families

The dynamic nature of family decision-making in EOL care creates ethical stress for nurses. This is particularly challenging when families reverse previously documented decisions, forcing nurses to navigate between conflicting obligations of patient autonomy and family wishes.

The most challenging moments are when families reverse DNR decisions during critical moments. We must suddenly shift from comfort care to aggressive intervention, knowing this might not align with the patient’s original wishes. (P02)

Watching families struggle with their decisions while trying to maintain our professional commitment to patient advocacy creates deep moral distress. (P07)

Theme 5: Actualizing Compassionate EOL Care

The delivery of dignified EOL care in EDs presents unique challenges that require nurses to balance technical competencies with humanistic care approaches. Despite experiencing moral distress, nurses continuously strive to maintain patient dignity through comprehensive care practices encompassing physical and emotional support. This commitment to dignified care persists even in challenging ED environments.

Subtheme 5.1: Creating dignity through purposeful actions

Nurses’ experiences revealed the importance of dignified EOL care in emergency settings. This care often manifests through seemingly small but deeply meaningful nursing interventions. These purposeful actions reflect the nurses’ understanding that dignity in death requires attention to physical comfort and emotional presence.

Cleaning the patient’s face, holding the family’s hand... These small actions mean so much when someone is nearing the end. (P12)

Making sure the patient is comfortable, even if it’s just moistening their lips or adjusting their position-- these small acts of care show dignity. (P04)

When families see us taking time for these little details, they feel their loved one matters. (P09)

Subtheme 5.2: Navigating environmental barriers to dignified care

ED nurses face major challenges in maintaining dignity during EOL care owing to environmental constraints. Despite these obstacles, innovative approaches have been developed to create spaces of dignity and comfort within chaotic emergency settings.

We struggle to maintain privacy when providing EOL care in our crowded ED. Sometimes, we’re forced to use temporary screens, but it’s far from ideal. (P05)

Creating moments of peace in chaos requires creativity and dedication. (P11)

Every small adjustment we make to improve privacy and comfort matters in these final moments. (P07)

DISCUSSION

In this study, we provided a qualitative exploration of nurses’ experiences delivering EOL care in EDs. Five themes were identified from the analysis: Inadequate Environment for EOL Care, Impact of Life-Sustaining Treatment Decision Complexity, Managing Care Relationships in Physician-Limited Settings, Challenges in Protecting Patients’ Rights, and Actualizing Compassionate EOL Care. These findings highlight the intricate challenges healthcare providers face in balancing the urgency of emergency care with the need for dignified EOL support.

Interestingly, while these findings align with studies that call for improved spaces in the ED, they also reveal the adaptive strategies nurses employ, such as utilizing makeshift private areas or expediting patient transfers to more appropriate settings. This adaptability aligns with Burnitt et al.[8], who reported that nurses often take the initiative to create a semblance of patient privacy despite environmental constraints. However, this improvisational approach highlights a systematic issue, suggesting that institutional changes are needed to prioritize EOL care within the fast-paced environment of the ED.

The second theme, the Impact of Life-Sustaining Treatment Decision Complexity, highlights the vast ethical challenges and moral distress that ED nurses face when navigating life-sustaining treatment decisions. Balancing medical necessities with cultural sensitivities and institutional constraints, all under the pressure of rapid decision-making intensifies this complexity. This finding aligns with that of Tiah et al. [6], who noted that healthcare providers often struggle with ethical dilemmas arising from the interplay of financial concerns, cultural norms, and legal obligations in treatment decisions. Our study emphasizes the complex dynamics of family decision-making in an East Asian context, where family dynamics and filial piety often take precedence over individual patient autonomy [20]. Nurses reported ethical challenges as they navigated conflicting desires between patients and their families, often complicated by financial constraints and legal requirements. This cultural dynamic creates tensions, contributing to moral distress among nurses and affecting their clinical judgment and ability to provide quality EOL care.

The ethical complexity of these situations is further heightened in emergency settings, where the pressure of rapid decision-making often conflicts with the need to maintain quality care. Nurses frequently find themselves torn between attending to acute emergencies and providing the necessary support to dying patients and their families. This compromise in quality care is consistent with Deng et al. [21], who highlighted the difficulties healthcare providers face in delivering quality care under time constraints. Additionally, new palliative care legislation adds another layer of complexity, as nurses must quickly adapt to updated protocols while ensuring ethical practices. Incorporating culturally sensitive communication strategies is crucial to bridge these gaps. Oczkowski et al. [22] advocated using standardized communication tools that can help deliver complex information effectively and alleviate decision-making burdens on families. Given the critical role cultural values play in shaping EOL care, healthcare systems must foster culturally informed practices and provide nurses with support mechanisms. This can help alleviate moral distress and improve the quality of care in these challenging scenarios.

The third theme, Managing Care Relationships in Physician- Limited Settings, highlights the severe challenges nurses face when physicians provide minimal information and delegate EOL care responsibilities. Nurses experienced moral distress and role conflicts as they navigated the delicate balance between supporting families’ urgent need for information and adhering to professional boundaries. This often places nurses in the difficult position of being the primary source of clarification and emotional support, which leads to substantial emotional and professional strain. Similarly, Anderson et al. [5] found that limited physician involvement in EOL discussions increased uncertainty and stress among family members, further burdening nurses, who must fill the communication gaps. The intense emotional labor in providing comprehensive support to families during critical EOL decisions cannot be overstated. Burnitt et al. [8] suggests that improving interdisciplinary collaboration can help alleviate some of these pressures by distributing communication and supporting responsibilities across healthcare teams. This approach ensures that families receive comprehensive care while allowing nurses to manage their expanded roles more effectively.

The fourth theme, Challenges in Protecting Patients’ Rights, discusses the ethical dilemmas nurses encounter when family decisions conflict with what the patient might have wanted. This finding aligns with Giabicani et al.[23], who identified the moral distress healthcare providers experience in navigating situations where family wishes override patient autonomy. In many cases, the lack of explicit patient directives puts healthcare providers in a difficult position where they must balance respecting the family’s wishes while advocating for the patient’s dignity. Furthermore, this study highlights the emotional toll on nurses as they try to protect patient rights without sufficient institutional support or ethical guidelines tailored to the emergency room context. Developing ethical decision- making frameworks and offering ethical consultation services in the ED can help nurses manage these complex situations more effectively.

Finally, the theme of Actualizing Compassionate EOL Care underscores the efforts made by nurses to offer compassionate care despite environmental and time constraints. Seemingly small acts of care, such as basic nursing tasks and emotional support, play crucial roles in ensuring a dignified EOL experience. This finding resonates with that of Aquino et al. [24], who argued that creating a calm and supportive environment is fundamental for meaningful EOL care. Similarly, Burnitt et al.[8] found that ED nurses often strive to integrate empathy and emotional support into their care routines despite the chaotic nature of their work setting. These efforts underscore the inherent compassion and dedication of ED nurses to uphold patient dignity, suggesting that with proper support and resources, the quality of EOL care in emergency settings can be considerably improved.

Our results highlight the critical need for systematic changes in emergency care settings. These changes include creating private spaces for EOL care, implementing culturally sensitive communication strategies, establishing ethical guidelines for decision-making, and enhancing interdisciplinary collaboration. Such efforts can promote a more holistic and humanized approach to EOL care in EDs.

This study has several limitations that must be acknowledged. The participant sample was drawn from a single tertiary hospital, limiting the transferability of the findings to other healthcare settings. Future research should involve multiple sites with varying characteristics to enhance the generalizability of the results. Additionally, using self-reported data from interviews may introduce biases such as recall bias or social desirability bias. Lastly, this study only focused on the perspectives of healthcare providers. Incorporating the viewpoints of patients and their families can provide a more comprehensive understanding of EOL care experiences in emergency settings.

CONCLUSION

This study offers valuable insights into the experiences of nurses providing EOL care in ED. These findings underscore the need for interventions that address the environmental constraints, cultural complexities, and ethical challenges inherent in emergency settings. A pressing need exists for private spaces, culturally sensitive communication strategies, and ethical guidelines to support healthcare providers in delivering dignified EOL care. Furthermore, the importance of interdisciplinary collaboration and integrating empathy and emotional support into emergency care practices has been emphasized. By addressing these multifaceted needs, healthcare systems can promote a more holistic and compassionate approach to EOL care in EDs.

Based on our findings, several recommendations are proposed. First, developing tailored educational protocols is crucial, considering the need for culturally sensitive communication among healthcare providers, patients, and families. Future studies should focus on creating such protocols and evaluating their effectiveness. Second, shared professional-specific guidelines should be established to enhance nurses’ knowledge and decision-making abilities regarding EOL care. Research exploring the impact of these standardized guidelines on clinical practice would be valuable. Lastly, to address the difficulties in collaboration arising from role expectations among nurses, there is a need to create forums for open discussions among healthcare professionals. These forums can foster understanding, reduce conflict, and improve teamwork in the delivery of EOL care.