Defining dignity in end-of-life care in the emergency department

Abstract

Background:

Respecting dignity is having a profound effect on the clinical relationship and the care framework for terminally ill patients in palliative care units, hospices and their own homes, with particular consequences for the emergency department. However, dignity is a vague and multifaceted concept that is difficult to measure.

Objective:

The aim of this study is to define the attributes of dignity in end-of-life care in the emergency department, based on the opinions of physicians and nurses.

Research design:

A hermeneutic phenomenological approach utilising Gadamer's philosophical underpinnings guided the study.

Participants and research context:

This research was conducted in Spain in 2013–2014. Participants included 10 physicians and 16 nurses with experience working in the emergency department. Two focus groups and 12 in-depth interviews were carried out.

Ethical considerations:

The study was approved by the Research Centre Ethical Committee (Andalusian Health Service, Spain).

Findings:

The results point to the person's inherent value, socio-environmental conditions and conscious actions/attitudes as attributes of dignity when caring for a dying patient in the emergency department.

Discussion:

Dying with dignity is a basic objective in end-of-life care and is an ambiguous but relevant concept for physicians and nurses. In line with our theoretical framework, our results highlight care environment, professional actions and socio-family context as attributes of dignity.

Conclusion:

Quality care in the emergency department includes paying attention to the dignity of people in the process of death. The dignity in the care of a dying person in the emergency department is defined by acknowledging the inherent value in each person, socio-environmental conditions and social and individual acceptance of death. Addressing these questions has significant repercussions for health professionals, especially nurses.

Keywords

Dignity dying emergency medicine palliative care terminal care

Introduction

Although the majority of medical interventions have traditionally sought to cure the patient, social evolution is altering human beings’ understanding of recovery, life and death.¹ However, the debate regarding the quality of care for dying patients continues.² The gradual ageing of Western societies has increased expenses relating to the care of patients with chronic illnesses,³ making the costs of providing end-of-life care in acute-care hospitals unsustainable.⁴

This new care framework has led to significant changes in terms of experience, treatment and care throughout the end-of-life process.⁵ Within this context, death is associated more with a scientific failure than with an inevitable step in a human being's life cycle. Not acknowledging imminent death, together with a lack of knowledge or inconsistency regarding palliative care, may result in a dying patient going to the emergency department (ED). However, the ED is not a place designed for death; here, the body of a dying person is ‘matter out of place".⁶ For a patient who is terminally ill with cancer, a chronic and/or degenerative illness, the visit to the ED means coming face to face with the complex workings of the health system – fragmented and little prepared for their care.⁷ In the ED, the dying person will be confronted with problems of stress, communication,⁸ fear, loneliness and a lack of privacy, confidentiality and dignity.⁹

Respecting dignity is significantly changing the clinical relationship and the legal framework of care for terminally ill patients,¹⁰ with particular consequences for the ED.¹¹ From a Kantian perspective, dignity is rooted in a rational being's autonomy of will, able to give themselves laws, as this autonomous being should treat himself or herself and all others as ends in themselves and never only as mere means for other ends. But what constitutes the condition under which something can be an end in itself does not have merely a relative worth, that is, a price, but rather an inner worth, that is, dignity.¹² This principle presents will as a duty which does not rest on feelings, but (self) demands a relation with the use of said capacity from every human being – not obeying any other law than that which, being a rational, autonomous being, each human grants to themselves.¹²

This perspective may clash with clinical practice in the ED, where patients, families and health professionals are confronted with more than the technical care/treatment – they face futility and therapeutic limitations,^2,13 do-not-resuscitate orders,¹⁴ palliative sedation¹⁵ or advanced directives.¹⁶ Terminally ill patient care in the ED is contradictory;⁶ in an area focused on saving lives, the process of dying with dignity can be hampered.¹⁷ Defining dignity in the care of a dying patient in the ED from the point of view of physicians and nurses¹⁸ may be useful to understand patients and their families, develop plans to address their needs and improve end-of-life care.

Background

In Kantian terms, life in and for itself does not represent the highest good which has been entrusted to us, nor one which we should prioritise. It rather represents the idea that there are duties of a higher order. Acting freely lies in the fact that whoever values himself or herself does not fear death and faces it calmly and peacefully.¹⁹ A person has to feel that over their life, including at the end, they have lived with dignity; being a human being does not mean attempting to have a long life, but a dignified one.¹⁹

However, dignity is a vague and multifaceted concept that is difficult to measure.²⁰ The unbreakable ethical link between reason and will leads to rational behaviour, inasmuch as it is moral, including a knowledge and a will. Kant's study into human knowledge and moral philosophy argues that autonomy is recognised as the central phenomena of dignity and something to which every person has a right. Having dignity is something which is valued above anything else,¹² giving us satisfaction without the need for any other end.²¹ Every human being has dignity and has a right to have it maintained. Dignity exists in human beings,²² reflecting the individuals’ choices, values, ideals and lifestyle. Dignity should mean having cognitive ability, feeling comfortable with oneself and having control over one's behaviours and surroundings.²³ Respect, autonomy, empowerment and communication have also been identified as being the defining attributes of dignity.²⁴

Dignity is a social construction which mediates our relationships with others and is also an attribute of a good death for patients in the final stages of life. Dying with dignity is important for patients, their families and healthcare providers²³ and is a fundamental objective of quality end-of-life care. Maintaining patient dignity has always been considered synonymous with nursing practice, but if nurses are to provide dignity-preserving care, they need to know its attributes, the barriers and facilitators of clinical practice. However, the meaning of dying with dignity is ambiguous in the ED, where the preservation of dignity may be unintentionally overlooked.²⁰

Several legislative measures adopted in Spain have produced substantial changes in the regulation of the rights of terminally ill people in hospital.¹⁰ Legislation recognises the patients’ right to have an advanced directive, receive information and make decisions regarding their care. The inclusion of palliative care in the ED focuses on facilitating comfort, alleviating physical suffering and pain.²⁵ Although hospitals educate professionals in the preserving of dignity at the end of life, culture change is a lengthy, difficult task that cannot be achieved through laws alone.³ We thus need to understand its attributes in the patients, family members and professionals’ experiences in the ED.²⁶

H.M. Chochinov and colleagues^27
–29 identify several characteristics that can influence a patient's sense of dignity, and it is their model of dignity preservation which constitutes our framework. Chochinov's model identifies three central categories that explain the phenomenon of dignity at the end of life: (1) problems related to the illness – the ability of the patient to satisfy their basic needs themselves and the symptoms suffered; (2) repertoire of the preservation of dignity – perspectives of preserving dignity and actions or practices to do so; (3) the social dignity inventory – social concerns which influence a patient's dignity. Although Chochinov's model has been adapted to dignity in illness and end-of-life care,^30,31 its development in other areas would be recommendable. The aim of this study is to define the attributes of dignity in end-of-life care in the ED based on the opinion of physicians and nurses.

Method

Design

A hermeneutic phenomenological approach utilising Gadamer's³² philosophical underpinnings guided the study. As human beings, our existential nature – our being-in-the-world – allows us to comprehend ourselves within a historical context and a horizon of understanding. Understanding a phenomenon brings together preconceptions, theoretical knowledge, values and experiences. Human understanding is an interpretive process which involves a circularity of movement between the parts and the whole.³³ We understand a phenomenon through conversation; it is the encounter with others’ truth that allows something else to emerge.

Participants and setting

This study was carried out in the ED of two hospitals in Almeria (Spain) from 2013 to 2014. The participants, recruited through purposive sampling, met the following inclusion criteria: to be a physician or nurse, have a minimum of 2 years’ experience working in the ED and give consent for participation. The exclusion criteria considered were other professional categories (healthcare assistants, residents in training) or having suffered a personal loss within a year before starting the study (bereavement could act as a bias). The definitive sample was made up of 24 participants, with an average age of 39.6 years and an average experience of 14.9 years in the ED. The participants’ socio-demographic data can be seen in Table 1.

Table 1.

Socio-demographic data of the participants.

	Sex		Profession		Age (years)		Experience (years)
	Male	Female	Physician	Nurse	Range	Average	Range	Average
In-depth interview (n = 12)	5	7	4	8	30–49	40	3–26	14.3
Focus groups doctors (n = 6)	1	5	6	–	33–54	41.8	7–28	15.3
Focus groups nurses (n = 8)	3	5	–	8	28–48	38.1	6–25	15.3
Total participants (n = 26)	9	17	10	16	28–54		3–28

Data collection

Data collection took place between January 2013 and February 2014, through focus groups (FGs) and in-depth interviews.³⁴ Before starting, the participants were informed of the aim of the study and data confidentiality, and their consent was obtained. First, two FGs were carried out, one made up of physicians and the other of nurses, with six and eight participants, respectively, and taking an average of 51 min. Over the following months, in-depth interviews lasting between 60 and 90 min were carried out with eight nurses and four doctors (who had not participated in the FGs) in order to explore emerging categories and to expand our understanding of the study object. A question guide was used to conduct the interviews and the FGs (Table 2). All the FGs and in-depth interviews were audio-taped, transcribed verbatim, checked for accuracy, revised accordingly and prepared for analysis. Field notes were used to document reflections from the interviews, helping to clarify the process of analysis.

Table 2.

Interview guide.

Stage of interview	Subject	Content/example questions
Introduction	Motives	The belief that their experience offers information which should be known by everyone
Introduction	Aims	Carry out research to make said experience and information known
Start	General introductory question	‘If you don't mind, we'll start with you telling me about your experience of dignity in end-of-life care in the Emergency Department’
Development	Guide for conversation	‘What does the term dignity mean to you?’ ‘What leads you to believe that your patient has lost his/her dignity?’ ‘When do you feel your patients conserve their dignity in end-of-life care?’ ‘What do you think about dignity in end-of-life care in the Emergency Department?’
Finish	Final question	‘Is there anything else you would like to say on the subject?’
Finish	Thanks	Thank them for taking the time to talk to us Remind them that their statements will be of great help to us

Data analysis

In the analysis of FGs and interviews, a modified form of the stages developed by Valerie Fleming et al.³⁵ was used. The first stage was to decide whether the research question was pertinent according to methodological assumptions. When asked the question, Can dignity in end-of-life care in the ED be explored from a hermeneutic phenomenon perspective? the reply was affirmative. The second step identified the researchers’ pre-understanding of the study object, derived from their clinical experience in the ED and critical care, and their teaching and research experience in end-of-life care. The third step was to gain an understanding through dialogue with the participants via the text. To integrate the whole text with the reader, we carried out an open reading corroborating that the text talked about self-esteem, autonomy, respect and/or coping. Conversation was subsequently carried out between the researchers and the participants through the text, asking questions such as Is the ED a dignified place to die? During interpretation of the data, the meaning of each sentence was analysed, revealing units of meaning, sub-themes and themes. An example of the analysis process can be seen in Table 3. New questions arose, such as What differentiates dying patient care in the ED? leading us back and forth in accordance with the hermeneutic circle.^32,35 The coding which followed was performed by three researchers, one of whom was a nurse in the ED. Understanding was then extracted through the fusion of the participants’ and the researchers’ horizons. The fourth step was to establish reliability, identifying the different stages of the research process. Credibility was derived from the fact that all of the study participants’ opinions were represented and confirmability was achieved by returning to participants at all stages of the research process. In addition, the final list of themes and quotes was confirmed by all participants. ATLAS.ti 7.0 software was used throughout this process.

Table 3.

Example of the analysis process according to stage 4 of Fleming's study.³⁵

Quote	Initials codes	Units of meaning	Sub-theme	Theme
Before, death was seen as something natural and people wanted it to happen in the comfort of their own home, surrounded by their closest family and friends, by those who formed part of their life and gave it meaning. (Nurse-3)	Acceptance Accompaniment Socio-cultural change Dignity Dying at home	Death as something natural	Social acceptance	Socio/environmental conditions
Dying accompanied by your family, in a calm environment, in silence and at peace – I think that makes up part of ‘dying with dignity’, and this is completely the opposite of dying in the emergency department. (Physician-2)	Accompaniment Dignity Silence Calmness Unsuitable place	Dying in company Peaceful environment	Facilitating accompaniment	Socio/environmental conditions

Rigour

Methodological rigour was ensured at each stage of the study; all members of the research team determined the questions and the reliability of the coding as well as evaluating the evidence through the compilation of data.³⁶

Ethical considerations

All participants were informed of the purpose of the study, the voluntary nature of their participation and the commitment to confidentiality and anonymity, obtaining informed consent. The study was approved by the Research Centre Ethical Committee (Andalusian Health Service, reference number 04/06/12).

Findings

Three main themes defining dignity in the process of dying in the ED emerged in data analysis (Table 4).

Table 4.

Themes, sub-themes and units of meaning.

Theme	Sub-theme	Units of meaning
Inherent value in the person	Human quality	The intrinsic and supreme value which each human being possesses
Inherent value in the person	Self-esteem/respect	Dignity has a clear relationship with self-esteem Dignity is the word with which we demand respect
Socio/environmental conditions	Social acceptance	Death as something natural
	Respecting the autonomy of will	Feeling masters of our own lives Freedom to make decisions regarding important matters. Capacity to decide
	Humanising care	Avoiding technification Easing massification
	Facilitating accompaniment	Dying in company Peaceful environment
Conscious attitudes/actions	Coping with decorum	A way of behaving in life
Conscious attitudes/actions	Respecting human rights	A set of rights and duties Human rights

Theme 1. Inherent value in the person

Dignity is primarily understood as a human quality, as the meaning of dignity is rooted in recognising a valuable person in a human being, an attribute which is inherent and unconditional for him or her. It is therefore a human condition, as only a human being is aware of possessing, demanding and, where relevant, losing it. Two sub-themes emerged from within this main theme.

Sub-theme 1. Human quality

It is human nature to treat people according to their dignity, a duty to which, in Kantian terms, even life itself would have to submit. Mankind represents its own existence like this – each subject is an end in itself and their endings are everyone's. Dignity manifests itself in interaction and respect for oneself and others, even more so in situations of extreme vulnerability:

It's the intrinsic and supreme value which each human being has, regardless of their economic, social or cultural situation, or their beliefs or ways of thinking. (Physician 3)

The first thing that comes to mind when I hear the word dignity is that it's an inherent quality of human beings as only they are able to be aware of losing it. Although animals have the right to a dignified death, only human beings are able to take action to make it happen. (Nurse 4)

Sub-theme 2. Self-esteem/respect

The participants related dignity to the self-esteem and respect we owe ourselves and others. Overvaluing life may be linked to a lack of self-esteem, stopping the patient from facing death peacefully. Respect is a spontaneous feeling, a reflection of being aware of the subordination of will to a law imposed by ourselves. Removed from utilitarianism, a dying person's dignity in the ED responds to a demand for respect and care – a moral good supported by an attentive eye and prudent approach to the uniqueness of the individual:

Dignity has a clear relationship with self-esteem – it signifies the human quality in every one of us. (Nurse 3)

By dignity, I understand respect for the human being, respect which should be extended to all levels of the person. (Physician 1)

I think that, when with a terminally-ill person, we act in a way which makes them see that we feel a profound respect for them, that we listen to them, that someone cares what happens to them, we don"t only carry out our professional responsibilities, but also help them to die a dignified death. (Nurse 6)

Theme 2. Socio/environmental conditions

This category encompasses the physical space, professional conduct and/or privacy, factors which contribute to a dying patient's feeling of dignity. It is similar to what is known as the social dignity inventory in our theoretical framework. Attending to these conditions may act as an agent of culture change for care in the ED. Socio/environmental conditions in the ED was an emerging theme for the participants, divided into three sub-themes.

Sub-theme 1. Social acceptance

Part of our condition as human beings is the quality of being mortal, an ontological contingency, an expression of fragility, decline and finitude. However, post-industrial societies have confused the process of death, displacing it from the domestic to the hospital field. Surrounded by scientific-technical equipment, concealing death, the rites and the grief permeates the institutionalised dying person, with consequent issues of loneliness, therapeutic obstinacy, prolongation of agony and the expropriation of the experience of death itself. For the participants, respecting the dignity of the terminally ill patient in the ED means reflecting on the socio-cultural acceptance of death and the finitude of the human condition:

I think life is very medicalised now and patients and/or family members turn to medical support for virtually anything. (Physician 2)

Before, death was seen as something natural and people wanted it to happen in the comfort of their own home, surrounded by their closest family and friends, by those who formed part of their life and gave it meaning. (Nurse 3)

In the past, somebody died and the family dressed them, with shrouds and kissed them … I even did my grandmother's hair … Now it seems to scare people. (Nurses’ Focus Group)

Sub-theme 2. Respecting the autonomy of will

For Kant, human dignity is founded on autonomy, in the capacity of each human being to give themselves rules and make decisions. Autonomy is an unconditional value, incomparable and independent of status and circumstances. Environmental conditions may influence autonomy, an attribute of the dying person's dignity in the ED acknowledged by the participating nurses:

By dignity, I understand a physical, psychological and even social state which makes us feel masters of our life and as such, our own actions – it enables the taking of decisions in order to face consequences of death peacefully. (Nurse 2)

For me, the term dignity means having the ability to decide, if possible, how we want to be treated in a specific situation and/or if not, to have somebody to help or manage decision-making with regard to social and psychological care and help us to experience the last moment of our life – death – how we want. (Nurses’ Focus Group)

Sub-theme 3. Humanising care

The ‘technification’ of medicine and the massification of public health systems have had a special impact on the ED. Prepared to preserve life, here care is focused on monitoring vital signs and carrying out invasive procedures. However, these patients do not require saving-life procedures, but would benefit from palliative care instead. For this reason, they feel helpless, in a depersonalised environment which infringes upon their dignity:

Between the monitors, the pumps, the chaos, the knocking of beds … this isn't a dignified place for a terminally-ill patient … who should be peaceful, in a room and dying comfortably … people should die with the same dignity that they have whilst living … not in the middle of a corridor … where the whole world can see you … without your family … with the feeling of being abandoned. (Nurses’ Focus Group)

Because of the place itself – it's not suitable, the atmosphere that you're surrounded by … it's not the best place – the family can't be there, the furniture itself … I don't know … everything that surrounds it for me … it's not dignified for the patient … the technification, the noises … (Physicians’ Focus Group)

Sub-theme 4. Facilitating accompaniment

Our participants recognised an attribute of dignity for terminally ill patients in the ED in this accompaniment. They need their loved ones to be close to them, to share their feelings, to resolve pending issues and to say goodbye. They need contact more than ever, closeness, time and someone to listen. The family environment, the comfort and peace of the home create the ideal setting for accompaniment – conditions of dignity which are difficult to reproduce in the ED:

Dying accompanied by your family, in a calm environment, in silence and at peace – I think that makes up part of ‘dying with dignity', and this is completely the opposite of dying in the emergency department. (Physician 2)

[To ensure people's dignity] It's necessary to accompany them and comfort them when I have nothing else to offer them. Consoling and accompanying the families. (Physician 1)

A lot of the time, the important thing is not where you die, but how and with whom you die. (Nurse 6)

Theme 3. Conscious attitudes/actions

The participants identified dignity with a series of conscious actions such as confronting life situations, behaving with decorum and/or respecting human rights.

Sub-theme 1. Coping with decorum

Being concerned about the person's integrity forms part of dignity in end-of-life care in the ED. Understanding the existential reply when anticipating death implies going beyond the facts; it implies a flow of emotions. This moral viewpoint of finitude shapes a ‘being there knowledge’ when facing the process. In the eminently technical care framework, respect for individuality, looking and listening attentively, together with sensitivity, were recognised by the participants as attributes of dignity:

It's something intangible, a way of facing specific situations with decorum, a way of behaving in life, and not only in critical situations. (Nurse 1)

The patient doesn"t lose his/her dignity – sometimes it's actually us, the others, who lose our dignity when accompanying them. (Physician 1)

There are ill people in wheelchairs or experiencing their final days in a hospital bed who show generosity, deep joy, maturity and true inner strength, which is an invaluable example for all around them, making it a privilege to care for them. (Nurse 3)

Sub-theme 2. Respecting human rights

Human rights represent instrumental conditions which allow a person to lead a dignified life. A human being's dignity cannot be substituted for anything equivalent, nor can it obey a different law than that which we give ourselves. It is thus a source of right which transcends the mere will of the health professionals. Undervaluing a person's dignity is reflected in a violation of his or her rights. The physicians and nurses in our study identified respecting human rights as an attribute of a dying person's dignity in the ED, something which should be reflected in duties:

A person's dignity implies a group of natural duties and rights, the right to honour, to intimacy, to a good reputation, to one's own image, to physical integrity … All these needs which people and communities possess to be able to live in a dignified way constitute human rights. (Nurse 3)

Human rights are a value […] without which neither life nor dignity can exist. And this value of each human being should be respected and protected. (Physician 4)

Discussion

The objective of our study was to define the attributes of dignity in end-of-life care in the ED. Not acknowledging imminent death, together with a lack of knowledge or consistency regarding palliative care services,⁶ drives a dying patient to the ED. Dying with dignity is a basic objective in end-of-life care and is an ambiguous but relevant concept for physicians and nurses.²³ When faced with exacerbated symptoms or a worsening process, terminally ill patients attend the ED, where care models may complicate this stage of life.⁴

Dignity refers to an intrinsic value in every human being, more than the preservation of one's own life.¹⁹ Even when facing terminal illness and a bad prognosis, a patient is a person with worth who deserves to be treated with care²¹ and possesses an absolute dignity, a source of rights and obligations. A dying person's dignity in the ED is associated with self-esteem and respect; safety, autonomy and integrity are all inviolable attributes.²² Understood as the value which we give ourselves, the way in which we perceive and regard ourselves as an end,³⁷ self-esteem is associated with dignity. For the physicians and nurses in our study, dignity is a word with which we demand respect for ourselves. As in a hospice or at home,³⁸ the threat to the self, the functional inability and the dependency on others may impair dignity and thus the value of palliative care and anticipated planning in the ED.^39,40 This coincides with our theoretical framework, where continuity of oneself and autonomy for self-care are elements in the conservation of dignity.^27,28

In line with our theoretical framework,^29,31 our results highlight care environment, professional actions and socio-family context as attributes of dignity. For the nurses, a good death in the ED implies the control of symptoms, relief from suffering and help to substitute and satisfy the dying person's basic needs.⁴¹ As in other studies, the participants identified a threat to the patient's dignity in the socio-environmental conditions.³⁰ In the ED, it is difficult to have adapted facilities available,⁴² as well as privacy and individualised care, lacking time and previous links with the patient and the family.⁸

In line with our theoretical framework which acknowledges resilience, a fighting spirit and acceptance are key elements in the preservation of dignity;^28,31 for physicians and nurses in our study, social acceptance is also an attribute of dignity in the ED. Being conscious of death may improve individual and social preparation, although barriers still remain.⁴³ The objectification of death and the reification of the body lead to a disassociation with the dying person in the ED, to hiding rites and grief.⁴⁴ Social non-acceptance of death, together with the lack of advanced directives, generates distress, suffering, rage and helplessness.⁴⁵ Helping the family to start the grieving process, respecting individual differences, may contribute to the dying person's dignity in the ED. As seen with the older people,⁴⁶ the presence of the family with the dying person can dignify care and reduce visits to the ED.

Kant¹⁹ associates human dignity with autonomy, which could go as far as to require ourselves to confront our own death rather than ‘dishonour all humanity in our own person, turning it into something for outside law/judgement'. We are the first generation that can decide how to die.⁴⁷ Passing through the ED is thus a good opportunity for the patient to discuss advanced planning. Autonomy and empowerment have been identified as attributes of dignity;^27

–31 however, the ED is a place where professionals’ definition of palliative care remains contradictory and dignity can be unintentionally overlooked.⁴⁸

Practices related to maintaining a dying person's dignity point to the continuity of one's self and the conserving of roles.²⁷ For our informants, facing the process includes conscious actions focused on continuing as normal, carrying out routines, achieving short-term goals and/or facilitating the expression of beliefs.⁴⁹ As seen in the Intensive Care Units,⁵⁰ dignifying a dying person's care in the ED implies managing emotions, reducing suffering and guaranteeing access to palliative care.⁴³ In contrast to our framework,^27,28 our participants hardly mentioned problems related to the illness; more than a physical suffering, they indicated a psychological suffering, uncertainty and distress.

One of the main categories of Chochinov's model^27,28 is the social dignity inventory, which refers to social support and boundaries of privacy. These attributes of dignity are also relevant in the ED.^9,31,51 Fear of medical care was also noted by the informants; as indicated by Guo and Jacelon,²³ it is others, including the professionals, who make the process undignified. Fear of intervention and unemotional, distant treatment may also destroy dignity in the ED, while access to palliative care may help to make the process more dignified. In this sense, nurses hold a unique and privileged position in patient and family care.⁶

With regard to study limitations, it should be noted that being a qualitative study, the results must be interpreted with caution; they are of value within the context in which the investigation was carried out. Furthermore, interviewing family members and patients could have found different results. For example, there are elements of Chochinov's²⁷ model which do not appear in our study, such as the dying person's feeling of being a burden to professionals and carers and after-concerns.

Conclusion

Quality care in the ED includes paying attention to the dignity of people in the process of dying. Prepared for saving lives, EDs do not attend to the patients’ needs at the end of their life. According to the physicians and nurses who participated in our study, dignity in the care of a dying person in the ED is defined by acknowledging the inherent value in each person in these circumstances, an intrinsic value of a human being, linked to self-esteem and respect. In addition to this, socio-environmental conditions in the ED also influence care and shape dignity. Social and individual acceptance of death, autonomy in decision-making, humanisation and accompaniment constitute attributes of dignity and may help in confronting and coping with the situation. Attending to these factors forms part of the patient's own human rights, as well as the health professionals’ duties for and with the dying person and the family, thus having profound implications for end-of-life care practice in the ED.

Footnotes

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

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