Advance care planning discussions in the emergency department can help increase documented goals-of-care conversations in patients’ medical records. However, this does not always increase patient-reported engagement, a recent clinical trial found.
The randomized clinical trial included 141 patients at three participating emergency departments at two academic medical centers and one community hospital in Boston. The hospitals were part of a single health system.
“These findings suggest that emergency department (ED) visits may serve as a critical access point for serious illness conversations in clinically stable older adults with advanced illnesses,” the study authors wrote. “Conversations between seriously ill patients and clinicians about values and goals can lead to patient-centered care toward the end of life. However, many patients have not had [serious illness conversations] when arriving in the ED and are at risk of receiving undesired care.”
Eligible participants were English-speaking adults 50 years or older with serious illnesses, including mild cognitive impairment or mild dementia, along with their caregivers. For patients with moderate to severe dementia, caregivers were the primary participants in the study.
Nurses who had been trained in conducting serious illness conversations held motivational interviews with patients and families about advance care planning, priming patients and their primary care clinicians to reinitiate those conversations on a tablet device in the emergency department or within one week of leaving the hospital.
The primary outcome was a validated survey of patient-reported engagement in advance care planning at one month, with total possible scores ranging from 1 to 5, with higher scores indicating more engagement. Secondary outcomes included clinician documentation of end-of-life values and preferences in the medical record and completed advance directives.
At 1 month, no difference was observed in patient-reported engagement in advance care planning. Among the participants, 12 patients in the intervention group discussed care preferences with their physicians compared with five in a control group. However, medical record documentation of end-of-life values and goals was significantly higher in the intervention group at three months.
About 75% of seniors visit the emergency department within one year of the end of life, according to the study. Clinician documented goals-of-care conversations can reduce health care costs by as much as 36%, the research indicated. However, only 37% of seriously ill seniors have had these conversations with their physicians.
“These conversations promote shared decision-making and improved quality of life at the end of life,” the study authors wrote. “For seriously ill older adults, SICs are associated with lower rates of in-hospital death, less aggressive care at the end of life, earlier hospice referrals, increased peacefulness, and a greater likelihood of having end-of-life wishes followed.”
