In the fast-paced world of emergency medicine, life and death often feel like binary outcomes. Yet, as Dr. Matt Hooper, an intensivist and palliative care specialist, discussed at the London Trauma Conference, there’s a middle ground that we as healthcare professionals must explore: how to integrate compassionate end-of-life care into acute settings. This podcast delves into the key themes of Matt’s talk and offers actionable insights for health professionals aiming to provide dignified, holistic care at the most critical moments.
Listening time: 24.57
Reframing Death in Emergency Medicine
Matt emphasized that modern emergency medicine has become synonymous with life extension and survival. While these goals are central to the discipline, they should not overshadow the importance of a “good death” for patients whose lives cannot be saved. He cited a 1984 quote that highlighted the need to assess not only survival but also the quality of life, the quality of death, and the quality of relationships surrounding a patient’s passing.
Recognizing death as a natural part of life—and not as a failure—is a crucial step in shifting this mindset. For emergency practitioners, this involves reevaluating our metrics of success and embracing care strategies that prioritize comfort and dignity when life-saving interventions are no longer appropriate.
Three Key Stakeholders in End-of-Life Scenarios
Dr. Hooper identified three groups affected by end-of-life situations in emergency settings:
- The Patient: Providing comfort and dignity should be central to care, even in environments like emergency departments or pre-hospital settings.
- Witnesses to Death: Families, bystanders, and colleagues are often secondary casualties. Matt emphasized the importance of recognizing their emotional needs to help them process grief and avoid long-term trauma.
- Healthcare Providers: Responders often carry an “accumulated burden of grief,” which can lead to burnout or PTSD. Addressing emotional connections to patients and their families can be preventative, fostering resilience instead of emotional detachment.
Bridging the Gap: Applying Palliative Care Principles in Acute Settings
The Importance of Communication
Matt stressed the need for clear, compassionate communication. Avoid terms like “withdrawing care” or “ceiling of care,” which can imply abandonment. Instead, frame the shift as one that focuses on comfort and dignity. By saying, “I guarantee we will do everything necessary to ensure their comfort and respect their dignity,” you help families feel supported without burdening them with decisions beyond their expertise.
The Role of Silence
Silence can be a powerful tool. When presenting difficult truths to families, resist the urge to over-explain or fill pauses. This gives them space to process information and respond meaningfully.
The Pause
One specific technique Matt highlighted is “The Pause,” a practice borrowed from hospice care. After a patient has died, the team collectively acknowledges the life that has ended. A simple, non-denominational script can help:
“Before we move on to care for others, let’s take a moment to honour [the patient]. They were someone’s loved one, and their life mattered. We value the opportunity to have cared for them.”
This practice not only supports the emotional health of the team but also humanizes the experience for witnesses and family members.
Training for Compassionate Resuscitation
While postgraduate palliative care qualifications, like those Dr. Hooper pursued, may not be feasible for all practitioners, there are ways to build competency:
- Use the Surprise Question: Ask, “Would you be surprised if this patient died in the next 12 months?” This simple tool helps identify patients who may benefit from early palliative interventions.
- Develop Communication Skills: Attend short courses or workshops that focus on breaking bad news, active listening, and handling emotionally charged situations.
- Leverage Resources: Explore literature and case studies on integrating palliative principles into emergency care.
Matt also called for the development of structured “last aid” training—a curriculum akin to first aid but focusing on end-of-life care.
The Emotional Toll on Healthcare Providers
Healthcare providers are often reluctant to confront their emotional responses to death, fearing it might impair their professionalism. However, Dr. Hooper argued that acknowledging and addressing these feelings can enhance resilience and empathy. Leaning into the discomfort of difficult conversations or emotionally charged scenarios, rather than avoiding them, allows practitioners to build emotional stamina and provide better care.
A Vision for the Future: Compassionate Resuscitation
Matt proposed merging the principles of acute care and palliative care into a unified framework he calls “compassionate resuscitation.” This approach emphasizes the following:
- Treat What is Treatable: Focus on reversible and manageable conditions while recognizing when interventions may cause more harm than benefit.
- Humanize Care: Utilize soft skills such as touch, eye contact, and tone of voice to comfort patients and families.
- Respect Individual Paths: Acknowledge that patients “die as they have lived,” and allow their values to guide care decisions.
Practical Takeaways for Health Professionals
- Incorporate The Pause: Make it a routine part of your practice to acknowledge death, both for the team and for those grieving.
- Foster Open Dialogue: Normalize discussions about end-of-life care within your team and with patients and families.
- Seek Training Opportunities: Engage with resources that improve your ability to identify and respond to end-of-life scenarios.
- Advocate for Change: Work within your institution to develop policies and training programs that prioritize compassionate end-of-life care.
Conclusion
Matt’s insights challenge us to rethink how we approach death in emergency medicine. By integrating palliative care principles into our practice, we can provide care that is not only clinically excellent but also deeply humane. Compassionate resuscitation is not about choosing between life and death—it’s about honouring the full spectrum of the human experience.
Podcast Transcription
WWelcome to the St Emlyn’s podcast. I’m Iain Beardsell
and I’m Natalie May
and we are at the London Trauma Conference and it’s a great pleasure to welcome all the way from Adelaide Matt Hooper. Matt has a fascinating career pathway, which I’m sure he’ll share with us now.
And in fact, Matt, it’d be much easier for you to introduce yourself than for me to try and go through all the different things you’ve done.
Thank you very much for inviting me to the podcast, and you’re right, my, my career has been, in some ways circuitous. And if you looked at it superficially, it would, at times perhaps look conflicted and not make a lot of sense, but I have moved from initially emergency medicine specialist training through, quite a lot of pre hospital and retrieval medicine, which I continue to be involved in, to intensive care medicine, which I continue to be involved in, and more recently into the palliative care and end of life care space.
And your talk today was about well focusing on death at scene really and how we can do that better but it really went into other things as well about allowing people a good death and thinking about what we do because we have to do it and we’ll explore all of that during our conversation now. What do you think were the key messages you wanted to get across to the audience this morning? Many of whom are in the throes of wanting to save lives and your talk was actually designed on something completely different. So I imagine it was a little bit intimidating when it came to stand up and talk to them about it.
It was an interesting process to go through, in fact, personally, to put this talk together.
The really hyper acute end of life care at scene, that unexpected or traumatic death is even,difficult for me to get my head around as to what palliative care, end of life care principles are relevant for a start.
Our specialty is, necessarily based on and continues to be based on survival, as a measure of . quality as a measure of outcome. We are a collective group of envelope pushers, of death defiers, of life extenders.
And we are getting very good, at some of those areas of life extension. And I don’t think the two are binary. Extending life, I’ve never saved a life, I’ve extended many. But I think the extending life that we do is really important, it’s critical work. But alongside that can be the consideration of end of life care, particularly for patients, who are not able to be, whose life or quality of life and let alone length of life are able to be improved with the input we have. Our whole specialty is based on the outcomes of survival. and that mortality is seen as an a negative, and as a result we are death, deniers for good reason. You look at,all of the papers and much of the technology that’s been presented is all based on survival. The question I posed was, is it all about survival? and I used a quote that interestingly was written in 1984, which really said,
that intensive care and the outcomes and the quality,shouldn’t see death as a medical failure, but we should also see those that survive and the quality of their lives as a quality measure. And also the quality of those deaths for those in whose interest it is to die. And also for the quality of relationships that are involved in each death.
Firstly, that was written in 1984, so I think for a long time we’ve recognised that as we get better and better at supporting people, who need invasive and intensive life supports, that eventually, we may lose track of those people who we cannot extend or save, those patients who will die, and our focus, I think, has drifted somewhat, particularly in the acute care space, perhaps less so now in intensive care, but I think still in emergency medicine, and I don’t think we’ve even considered it in pre hospital care.
And so I put it to the audience
that, those measures of how do we measure the quality of death, and how do we measure the quality of relationships involved in each death were quite foreign. and I certainly have never been educated. on that. I’ve never audited it. I’ve never thought about good measures, really, until I started down my path in the palliative care space.
And the palliative care colleagues have some wonderful tools to measure quality of death. Most of those are around the palliative care cohort of patients. Many are based in hospice or home hospice or a hospital environment. And I’m not so sure those quality measures are necessarily applicable to the emergency department, let alone the streets.
Most of the palliative care patients I see and an increasing number of the retrieval patients we care for have quite chronic comorbid illness and many of them have life limiting illness diagnoses as well. And there are some really good measures in the palliative care space for those people’s quality of death and trajectory, but I’m not so sure they’re also applicable to those that die suddenly or traumatically, in the out of hospital environment.
When we then broke it down, I tried to look at how could we improve the outcome for patients, obviously, but also those who are witness to death in the out of hospital environment. They might be bystanders, they might be family or significant others. And it was really only my time in London, some decades ago now that I was introduced to this concept of the secondary casualty: the driver of the train, the driver of the bus, the family member, the child in the corner witnessing, what was happening and that recognizing them and responding to them was it was an important part of our role and more and more I’ve recognized that the way we interact with those people on scene may have both a negative impact for their forward journey, particularly in the way they grieve, and equally, if we do it really well, can have a very positive impact on their journey as they grieve and go forward.
And then the pre hospital teams themselves, the responders. how do we be more in touch with our emotional state and how do we connect our actions and emotions? And is that important? And in fact, is that even preventative for things like burnout and PTSD? That if on a regular basis we’re just touching, the humanness that we share with what has just happened, is that in fact preventative rather than risky?
I talked to a group of paramedics couple of weeks ago in Adelaide, at the end of which, interestingly, those that had been intensive care paramedics for 30 years said they’d never had any education on death, or death at scene, or managing death. But also, they recognized that they had this accumulating burden of grief.
And I think that’s the real risk for burnout and particularly PTSD. I think it’s more the accumulation of grief than one particular event.
So we’ve probably got three cohorts of people, haven’t we? We’ve got the patient themselves, we’ve got the care providers of whatever that may be, and then we’ve got the people who are witness to what’s happening.
And behind all of this, as you say, there is a binary feeling that life and death are a yes and no answer, rather than a graduation of something that happens naturally, and that death is a failure. . I think we all do, as you say, if somebody dies in the Resus room or pre hospital, something bad must have happened.
For each of those three groups, how do you think we can approach it to make death more acceptable? And also for particularly caregivers, when can we recognize that the things we are doing are more harmful to the three groups I’ve said, rather than helping, and particularly just we’re doing it to protect ourselves from others around us.
I’ll probably answer your question with the way I approach it in intensive care, because I think there is relevance across the spectrum of acute medicine, pre hospital, ED, ICU. And one is a recognition that I think we collectively as clinicians, but also family and even patients for that matter, feel overburdened with this potential need to make a decision that’s somehow binary. Every day I pick up the paper and see that, the family had to make the heartbreaking decision to switch off life support.
As an intensivist who manages end of life care all the time, that never happens, the family’s never asked, to make a heart breaking decision. And when I really distilled, what would be more useful, ultimately, it’s very easy to do everything in intensive care and critical care.
It’s very easy, relatively, to do nothing, to be paternalistic and to say, I’m not doing this, this is futile, this is ridiculous. The really difficult bit is working out the bit in the middle, what the patient,. might benefit from, what is treatable, what is reversible, what’s reasonable, given what you know of them, what’s unreasonable.
So I actually think more of our role should be just exploring almost these gate posts of a person’s trajectory. working through at all points and on a daily basis, what is treatable, what is reversible, what is reasonable, and what is unreasonable. Because ultimately the patient will tell you if they’ve got the capacity to get better or not.
And in intensive care I find that reframing for family incredibly positive. I can see them literally, relax. That, that I wasn’t going to be asking them to make the heartbreak decision or something like that. Because I, and I often say to family, I would love to be in control of the outcome. And I know you would. And I know your loved one would. But we’re not. And our role is to do these things we can. And I guarantee you amongst the unknowns, and the unknowns are frightening, I’ll do everything in my power to get them through. But I also guarantee you I won’t put them through anything unnecessary, and if they tell us they don’t have the capacity to get better, we’ll listen to that and shift the focus.
So I think the, which relates to, I guess, the importance of language. You hear, withdrawal of care, as a good example, or a ceiling of care. When do we ever withdraw care? When do we ever put a limit on the care we will provide for people? Of course, never.
It’s just the wording, but it’s important, because what we actually do is shift the focus if that is what is necessary. And the focus is always on someone’s comfort and dignity alongside the life sustaining measures. At some point, it might be entirely on their comfort and dignity. And no less important, no less rigorous in terms of how we approach their symptoms and how we might make them better.
How we palliate. Because the word palliate is just to make symptoms less. To lessen the severity. Accepting that the underlying disease may not be altered. So in essence, all of us, every day, practice palliative care. I think we just don’t recognise it.
I think as health care professionals, particularly those of us who work beyond the emergency department, and part of my job, I work as an inpatient trauma service where we have trauma patients for a long period of time. And I think what we get an understanding of that the public doesn’t is that sometimes there are fates worse than death. Do you have any advice on how to navigate that kind of that conversation when it’s happening very early for our patients?
One thing I learned, and very humbling, there were many lessons I learned going back to study and learning some palliative care principles, was that for a long time I’d wanted people to die on my own terms, in a way, or at least wanted to somehow impact that trajectory, whatever that was, because that was my job,
A colleague gave me some wonderful advice a couple of years ago when I had a death that was unexpected, I rang him for some advice. I said, look, I think, I really think I missed something. And we went through it to the nth degree and he said, I don’t think you missed anything.
And then he said something I think is really relevant, which is, we’re just not used to people dying without our permission anymore. The first thing I’d say is we need to be careful we’re not placing our own values on people’s lives. on to the outcome of the individual. The second thing I’ve learned is that people die as they have lived on their own terms, and allowing that to happen, allowing them to go through their own path is also important. And I’ve been humbled in both directions. I’ve seen people survive who, for every reason I’ve ever learnt out of every textbook should not have. And I’ve seen people that die where I’ve not really been able to ascertain why, other than the fact that they’ve decided to do so.
So I think there is this element that, that you also need to, to, let go, I guess, and, that this next bit will be up to your loved one. That’s the first thing I would say to family. I think though if you recognize that there is a big gap between expectation and reality, and that will come in different guises.
It might be someone with a life limiting illness who you can see has no further life. disease modifying therapies, for example, and is now in intensive care and is now critically unwell. And you might start talking to them or their family and realize that the focus is entirely on what’s next, what next treatment.
We’re just waiting for this drug and, access to that drug or trial or whatever it might be. And I think that’s a perfect opportunity for a warning shot. And again, another communication tool I learned through the palliative care space, which I think is useful, even in the resuscitation. for example, in that situation I might say, goodness, had you ever thought what would be important to you if there was no treatment left?
Third lesson is silence, right? I would then usually fill that gap with, because this, because that, and there is a fate worse than death, I think I’ve even used those terms, which is, I don’t think very useful. I think if you get the framing right, and you allow for silence, they will, they will understand.
Some families need time, but time is also reasonable. If you’ve set the boundaries of what’s treatable, what’s reversible, what’s not, what’s reasonable, what’s unreasonable, you do need some time to allow the patient to tell you if they will survive or not. Because, for some people, that’s their journey. For others, maybe not.
Just some practical things about how this relates to a day to day practice. So you’re an intensive care consultant with the palliative care alongside it. Does that mean that you are the man who shipped in to have these conversations or is your role one of education development of colleagues to try and bring them up to what you’ve learned?
How can people who are listening think about adding more palliative care knowledge into their daily work?
I think there’s two elements to it. So when I went into the palliative care, Postgraduate space, I actually went in believing we all needed to be better at having a really detailed conversation.
I’ve actually come around to a different view over the last couple of years, which is we all need to be really good at recognising who needs to have a really good conversation. So, one element of something we can do better, all of us can do better, particularly in the clinical care space, is identifying people who are waving a flag, really, to say I’m in the last 12 months of life. Or to say I don’t have much reserve. Or to say I’ve come to the end of those disease modifying therapies. To identify those people so that we can then explore their wishes and have those nuanced conversations where you listen to the second order things that are coming out. you give. a warning shot and allow time and space,
There are some really useful tools, simple tools, that we could be using straight away to identify people who we should be discussing, having better discussions with. The surprise question is a perfect example. That question that can be asked of any of the healthcare team looking after someone, would you be surprised if they died in the next 12 months?
If the answer is yes, from any healthcare teams,sensitivity and specificity is, mid, mid 60%. And if you add to that some simple tools or measures of chronic disease, life limiting disease or frailty, or, increasing frequency of hospital admission, those sorts of things.
You add those two tools together, our ability to recognize people is excellent. but our ability to respond to them is not. Well, I don’t think we actually recognise them either. I think, we don’t even look for it, really. And then when it comes to the conversation, I’ve come around to wonder if we could all have some, a much better tool kit with some of these communication skills and so on.
But perhaps that conversation isn’t as important. is in some ways an area of expertise, much like you can watch that surgeon know that tissue will take that stitch. And if you watch someone do these conversations extremely well, you’ll see these little pause points and the allowance of silence and the ability to hold space.
I do believe as specialists in the crit care area, we can all get good at that. and I guess my talk this morning was on the really pointy end. How can we use some of these skills that I’ve learned from. palliative care and hospice care when we are at the scene of a highly charged traumatic unexpected death, including those of children.
People listening might have fired their enthusiasm to think this is something I want to be able to do better, but they may not have the luxury of what you’ve been able to do with the postgraduate qualification at Cardiff University. What can people do now if they’ve heard this, it’s triggered a little bit within them saying I want to do this better.
How would you suggest people go about exploring doing this differently in perhaps a service where this is for most places, probably a little bit unheard of, dare I say, What would you recommend they do to try and increase their awareness? Other certain places people go, things that you would recommend in reading other more short form courses that can be done.
How can people really think about this themselves?
It’s an excellent question because I think, and the feedback from this morning has perhaps confirmed that there is a real gap here. necessarily because our focus has been on survival and mortality and pushing the envelope and death defying life extending.
I think we’re really starting to recognize that there is a need for some focused education in this space. There’s a lot of reading people can do, and doesn’t necessarily involve entry to a postgraduate degree. And, what I’ve found is that perhaps working in hospice all the time is not particularly useful for me either.
There’s this space in between the kind of end of life space, the palliative care space and this acute care space and that need is growing year on year. I think we all know it. And so there is this groundswell. There are many people, and some great minds I know out there that I hope will start to connect and start to put something forward.
Just like my career started with the very basic concepts of resuscitation of first aid, I learned how to look after wounds and do, basic life support, in the pools around my home in Adelaide and on the beaches when I joined surf lifesaving clubs.
And I had this interest in the emergency medicine space and, that was obvious early, I think coming full circle in my career now, that, whilst that just like that first aid course was so critically important for me, then we really need almost a last aid course. the ability to focus on the skills that are important,at the end, not just at the beginning.
One of the skills or techniques that you mentioned in your talk was the pause, which is a tool that you can use to bring the team together after a patient has died.
Can you just tell us a little bit about that? .
Not my tool, described by, I think, an emergency nurse from the U. S. originally. Interestingly, borrowed from, at least in its origins, the palliative care space. certainly there, there was, and still is, I think, the hospice in, San Francisco called the Zen Hospice Project, where, when, patients died, clients died, in that space, there was some formality of recognition, that person’s life had come to an end. And there was a short ceremony, almost, for want of a better word, that was non denominational, in any way religious, and it wasn’t enforced, it was voluntarily done by the staff and family, or anyone who wanted to join in. And there was this kind of recognition of that person, of their life, of that moment, and, and almost a celebration of that,
But there was this kind of little moment in time. And the pause as it relates to acute care emergency medicine, is in those moments where resuscitation has led to death. And we can all remember and vividly, in many cases, remember those moments when the momentum of what we’ve been doing suddenly shifts.
We’re in this highly charged, emotive, life saving, life extending, death defying mode. We might recognize that we need to shift the momentum, and that’s a whole other conversation, is how we recognize that and how we shift momentum of care. But then when the patient dies, you in the past at least, you would see people start to split off and someone might, start fluffing with the sheets or someone would start cleaning up the floor and someone might go and write a note and, everything just disperses as though nothing had happened.
There may be some show of emotion, but generally it’s like, okay, well, back to normal, next job. And in the pre hospital space, I think that’s been injurious for us. I really do. I think that has led, in some cases, to that accumulated grief. the end of that road is PTSD and, and career burnout.
So the pause is just that. In those moments, as a team leader, for example, I might invite the people, just to stay for a moment. And so before we go on to our daily work and, to caring for others, if you wish to remain, it might be helpful just to take a few moments to pause, and to recognize that this was somebody’s wife, son, husband, mother, daughter, that they had a life they had,and that for them, the world has ended.
And, we value the opportunity to care for them and perhaps what we learned from them. And although our efforts, didn’t lead to the outcome we’d hoped for, we just want to take a moment to respect what has happened. This team, this time, this person. And for a minute, you might just stay there. and I, the first few times I did this, it did feel awkward, but the feedback was incredibly powerful. and again, interesting. I Talking to this paramedic group the other day, I presented the pause concept. And the first thing I said, I can’t imagine doing that in front of family. yeah, it’s okay to do that in hospital, I wouldn’t do that in someone’s home, with a family there, and I said, take me through that, what’s the worst outcome of the family witnessing you touching your humanness.
And of course the outcome was there is no downside. In fact, there’s, I think, an enormous positive to doing that. These kind of things I’ve started to recognize is that the technical skills, the stuff we do, is critically important. And we have to be good at it.
We have to have attention to detail, we have to treat what’s treatable, reverse what’s reversible. That’s our job. But also, these skills of touch, of the energy you bring to a room or a space, of eye contact, of voice, these things heal. I’ve seen it in intensive care. Nothing else changes, but that.
I’ve seen it in hospice. You know, patients come in and I’m pretty convinced they’re going to die within hours, and they just get that nurturing, almost really, and they get better, to the point where they start saying, what’s happening? I’m supposed to be dead. I know and they might go home So I think there’s some power in that and to exclude that from our armamentarium It’s like taking our video laryngoscope out or our you know, one of our you know Antibiotic armamentarium or analgesic regimes.
These are powerful tools. So I think we need to include them The other is to lean in when we want to lean away You know, I still have days where I just don’t want to have that discussion. And I just don’t want to be in that environment. And I’ve learned that they are probably the very cases I have to lean into.
Patients die on their own terms as they have lived. I think that’s another important takeaway. And that ultimately amongst the cumulative horror that we all are witness to that being human might just be the superpower.
We talked about in the talk I talked about the leadership skills to be a resuscitationist in, and the behaviors that are required of resuscitationist .
And I put up next to that, the, behaviors and leadership style of managing potentially end of life in a hospice. And really you couldn’t really have more polar, opposite, the need to be in control, the need to, be somewhat emotionally dissociated, the need for action, decision, time criticality, And the other side, giving things time, abandoning, or at least, giving up to control sometimes, controlling only the things we can. And, and being emotionally connected. So the, and the point that came out of that was perhaps the way forward is to merge those two in an expert way.
So on one hand we have, resuscitation and on one hand we have compassionate end of life care. And the concept that I thought going forward would be useful is compassionate resuscitation. Matt, thank you so much for your time. It’s given me an awful lot to think about.
And that pause, there is a little script that you showed at the talk. There is. Which is in the blog post that you can use. And I guess people can bring out a piece of paper to remind themselves what to say.
It is. And in fact the one I displayed had, as you saw, probably had fold marks in it. That came out of one of my consultant’s flight suits, because he uses it also. So yes, I think it is very useful. It doesn’t have to be that script. But I think it is more the concept that is very powerful.
And I think humanizing the things we do, particularly in the times when we become least human, perhaps which is the Resus room or in the heart of those traumas.
Is a real power and it’s been really, should I say life affirming to chat to you to think about the things I can do differently and I hope it will be for listeners too.
The Guest – Dr Matt Hooper
Matt is an accomplished intensive care specialist with a diverse background in emergency medicine, prehospital & retrieval medicine, and palliative care.
Notable for his leadership in developing critical care service models, he founded South Australia’s MedSTAR Emergency Medical Retrieval Service. He has also co-authored a highly regarded case-based text book and held key teaching and examining roles nationally and internationally in prehospital and retrieval medicine.
With a strong focus on high-performance teams working within high acuity, high consequence environments, Matt’s expertise has also extended to human factors in healthcare, cardiothoracic intensive care, ECMO, and clinical ultrasound. More recently however, he has pivoted towards palliative and end of life care, pursuing a Master’s degree at Cardiff University and consulting at Mary Potter Hospice in Adelaide. He is passionate about exploring new and innovative ways to prevent potentially avoidable suffering and enhance end of life outcomes for patients in acute care clinical environments.

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