As the first point of contact in the healthcare system, the emergency department (ED) is particularly important for providing appropriate end-of-life (EOL) care, primarily when most EOL patients use emergency services in the last month of their lives. This highlights the need for more specialised training for emergency physicians to adequately manage the increasing number of patients towards the end of their lives.

EMPOWER (End-of-Life management protocol offered within emergency room) is a novel multicentre study aiming to improve the quality of end-of-life care for actively dying patients in ED via a multi-prong approach, from clinical charts and perceptions of family members at the bedside. The study employs a quasi-experimental interrupted time-series design using qualitative and quantitative methods, involving the three EDs of tertiary hospitals in Singapore over 3 years. There are five phases in this study: (1) retrospective chart reviews of patients who died within 5 days of ED attendance; (2) pilot phase to validate the CODE questionnaire in the local context; (3) pre-implementation phase; (4) focus group discussions (FGDs); and (5) post implementation phase. Post-implementation processes include quality assessment of the new care protocol and cost-effectiveness analysis.

The SCRI Epidemiologists provided pre-grant support to the PIs and clinical team by advising on the study protocol’s key study concepts and methodological aspects for the NMRC Health Services Research Grant application in 2017. With its high scientific merit, the team won then the largest grant award for the ED department. Epidemiology team members also provided streamlined post-grant support for IRB approval, the operational logistics by the Project Management, as well as designing and maintaining the Redcap database system by the Research Informatics in SCRI. Our Epidemiologists were invited to be Co-Investigators of this project as a recognition of their significant contribution.

Two manuscripts have been published for the study protocol and pilot phase.


Chua MT, Sen Kuan W, Zheng CQ, Tiah L, Kumar R, Wong YKY, Lin J, Liang S, Mayland CR, Shi L, Ibrahim I, Pal RY. Validation of "Care of the Dying Evaluation" in Emergency Medicine (CODE-EM): pilot phase of end-of-life management protocol offered within emergency room (EMPOWER) study. Ann Palliat Med. 2021 Jun;10(6):6145-6155. doi: 10.21037/apm-21-380. Epub 2021 May 25. PubMed PMID: 34118856.

Yash Pal R, Kuan WS, Tiah L, Kumar R, Wong YKY, Shi L, Zheng CQ, Lin J, Liang S, Segara UC, Yong WC, Chan NGC, Chua MT, Ibrahim I. End-of-life management protocol offered within emergency room (EMPOWER): study protocol for a multicentre study. BMJ Open. 2020 Apr 28;10(4):e036598. doi: 10.1136/bmjopen-2019-036598. PubMed PMID: 32350018; PubMed Central PMCID: PMC7213875.