The impact of COVID-19 on the knowledge, attitudes and practices of end-of-life care and decision making amongst doctors in South African Emergency Departments.

Introduction: The COVID-19 pandemic placed unprecedented strain on emergency departments (EDs), altering approaches to end-of-life (EOL) care. This study assessed its impact on emergency clinicians' knowledge, decision making and attitudes towards EOL care in Johannesburg, South Africa. Methods: We conducted a cross-sectional study among doctors working in five state-funded Johannesburg EDs between July 2024 and January 2025. A self-administered questionnaire assessed knowledge, attitudes, and practices across three peripandemic time periods: pre-COVID-19, during COVID-19 and post-COVID-19. Participants included doctors with ED experience both before and after the pandemic, and ED/ critical care experience during the pandemic. The survey included 10 knowledge items and Likert-scale assessments of attitudes and practices. Changes over time and associations with demographics were analysed, with p<0.05 considered statistically significant. Results: Ninety-three doctors participated (median ED experience 5 years). Only 11.8% reported formal EOL training, although median knowledge scores were high (9/10, IQR9-10). Attitudes towards EOL decision-making shifted significantly during the COVID-19 pandemic, with clinical prognostic factors (e.g., likelihood of survival, poor neurological outcomes, quality of life) increasing in importance, while medicolegal and religious considerations remained stable. Reported practices of withholding and withdrawal of life-sustaining treatment increased significantly during the COVID-19 pandemic and declined thereafter, suggesting an association with pandemic related pressures. In contrast, symptom management improved across all time points and EOL discussions became more frequent during and after the pandemic, particularly regarding prognosis and family involvement. Conclusion: The COVID-19 pandemic highlighted the ethical complexity importance of EOL care in South African EDs, alongside sustained improvements in communication and symptom management. These findings support the need for targeted EOL care training and system-level policy development to strengthen care in resourced constrained environments.