Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial

Abstract

Background Visits to the emergency department (ED) are inflection points in patients’ illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are (i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED and (ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes. Methods This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last 3 months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess (i) changes in ACP engagement within 6 months and (ii) qualitative assessments of the effect of ED GOAL. Discussion In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients’ self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes. Trial registration ClinicalTrials.gov identifier: NCT05209880

Experiences of Australian emergency doctors and nurses using advance care directives in the provision of care at the end of life

“…Even in circumstances, where there might be mismatched end‐of‐life expectations between the dying patient, the family, and staff members, ACDs were still able to provide some guidance into initiating conversations and communication of treatments goals 25–27 . Studies have shown that having ACDs and goals of care conversations in the ED setting with patients who were terminally ill but clinically stable are beneficial because it can set precedence for future management although preventing unwarranted treatments 28,29 . Similar to the research literature, participants in this current study stated that ED doctors were able to successfully predict the patients who had less than 12 months to live and yet an ACD was not always available 29,30 …”

“…[25][26][27] Studies have shown that having ACDs and goals of care conversations in the ED setting with patients who were terminally ill but clinically stable are beneficial because it can set precedence for future management although preventing unwarranted treatments. 28,29 Similar to the research literature, participants in this current study stated that ED doctors were able to successfully predict the patients who had less than 12 months to live and yet an ACD was not always available. 29,30 End-of-life care as a collaborative approach between doctors, nurses, patients, and families has been shown to improve care outcomes.…”

“…32 Recent studies exploring ED nurse led initiated conversations at the end of life showed improved communications between patients and clinicians. 9,28,33,34 Results of these studies indicate that nurses in ED have an expressed interest in taking an active role in helping patients at the end of life clarify their preferences. 35,36 A recent scoping review of articles exploring nurse led ACD training showed that there were numerous training modules available for nurses and doctors.…”

“…ED staff have skills in communication with a marked ability to develop rapport and therapeutic interactions with patients and families 32 . Recent studies exploring ED nurse led initiated conversations at the end of life showed improved communications between patients and clinicians 9,28,33,34 . Results of these studies indicate that nurses in ED have an expressed interest in taking an active role in helping patients at the end of life clarify their preferences 35,36 .…”

Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions

“…29 Another used ED-nurse-initiated serious illness conversations as a means to prime the patient for further GOC discussion with their primary provider. 30 What is unique and innovative about this current study is that we demonstrated that patients could be approached about GOC leading to a completed POLST during that visit in the ED.…”