A young man presented to a small rural Emergency Department where I was working in West Africa. He was wheeled in from the outpatient department, ashen gray with sweat pouring off his brow. The outpatient nurse told me he had presented two weeks earlier with a cough, was given antibiotics, and came back today looking close to death. I have never worked so hard to keep someone alive, but we didn’t have a ventilator or BiPAP machine that was desperately needed to assist his breathing. At a certain point, the team recognized there was nothing more we could do. My young patient died a few hours later, his last words to us being “I am suffering.” We gently wiped the sweat off his skin, and murmured consolations. 

In practicing Emergency Medicine, we are no strangers to suffering. The role of palliative care in the Emergency Department in regards to alleviating pain and addressing comfort at the end of life  is continuing to be defined and elaborated upon. In the global health setting, palliative care in the ED can take on a new meaning.

Palliative care represents an unmet global health need. In 2015, of those who died with serious health-related suffering, 80% of them were from developing regions (1). In Haiti, the amount of morphine-equivalent opioids distributed is 5 mg per palliative patient, compared to the 68,000 mg per palliative patient in Canada (1). The distance between these two realities is difficult to imagine. Some of the issues regarding the large gap in symptomatic relief of suffering includes lack of access to essential medications, the neglect of non-communicable diseases in the Global South, and the cultural emphasis in medicine on curative interventions and prolonging life, rather than attempting to provide care and dignity in death.

Many excellent suggestions have been made to address the gap in access to palliative care in general terms. Whether in humanitarian crises or scenarios of significant scarcity, death and suffering unfortunately are an inescapable reality. In the ED, that burden can be felt acutely and the drive to provide life-saving interventions is omnipresent. However, the imperative to alleviate suffering at the end of life cannot be neglected.

In health systems where specialists are few and far between, Emergency Physicians and generalists must be supported to address such broad needs. Faced with the demands of triage, providing acute care, managing inpatient cases, and administrative tasks, the role of caregiver in the vulnerable moments of death may fall to the wayside. This role of palliative care provider is no small task. Consider even the maintenance of dignity in death and dying. Infrastructure needs to be designed for compassionate care with private areas for dying patients and their families. Departments need to develop situationally feasibly palliative care protocols, and providers need more training on the specifics of culturally appropriate care practices (2). These are just a few examples of the institutional requirements to help Emergency Physicians take on this challenging arena.

While asking Emergency Medicine to accommodate greater needs for palliative care in a low resource setting, we also have to recognize the limitations imposed upon us. Triaging and prioritizing care in settings of scarcity is a necessary task. Even the humanitarian imperative to provide “the most good for the most people” can feel at odds with the ethic of providing compassionate care to each and every patient. Emergency Physicians in humanitarian settings have been found to experience moral distress when faced with the ethical dilemma of choosing where to allocate care (3). As one study described, there exists a “tyranny of low expectations” when physicians are only able to provide the bare minimum (3). If faced with a constant crisis of moral injury, how will we be able to persist as a field under such conditions? 

Despite these concerns, the fact remains that serious health-related suffering disproportionately affects the most vulnerable of patients and Emergency Medicine is situated to alleviate that suffering. Repeated study findings demonstrate that simple acts of care, such as bringing water to the bedside, provide profound meaning to the practice of palliative care in humanitarian settings (2, 3). The concept of “accompaniment” is also a common feature, walking families through the process of dying or ensuring that a patient does not feel abandoned or alone (2, 3). Compassion proves to be the center to which we can return, a recognition of the humanity in each of us. 

 

Dr. Sara Alavian training local health care providers in West Africa

References

1. Knaul, Felicia Marie et al. “Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.” Lancet (London, England) vol. 391,10128 (2018): 1391-1454.

2. Hunt, M., Chénier, A., Bezanson, K. et al. Moral experiences of humanitarian health professionals caring for patients who are dying or likely to die in a humanitarian crisis. Int J Humanitarian Action 3, 12 (2018)

3. Schwartz L, Nouvet E, de Laat S, Yantzi R, Wahoush O, Khater WA, et al. (2023) Aid when ‘there is nothing left to offer’: Experiences of palliative care and palliative care needs in humanitarian crises. PLOS Glob Public Health 3(2): e0001306

About the author:

Sara Alavian is an Emergency Physician and Assistant Clinical Professor at McMaster University. She completed her fellowship in Global Health and Emergency Medicine at the University of Toronto, and received a Diploma of Tropical Medicine and Hygiene in 2024. Her academic interests include health equity and global health. Her interest in global health involves knowledge translation, curriculum-sharing and capacity-building in low-resource settings for delivery of excellent Emergency Medicine care.