Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA.
Ann Emerg Med. 2019 Aug;74(2):276-284. doi: 10.1016/j.annemergmed.2019.01.003. Epub 2019 Feb 13.
During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.
在生命的最后 6 个月，75%患有预先存在的严重疾病的老年人，如晚期心力衰竭、肺病和癌症，会去急诊部（ED）就诊。ED 就诊往往标志着这些患者疾病轨迹的一个转折点，表明他们的衰退速度更快。尽管大多数患者去 ED 是为了寻求急性问题的治疗，但他们中的许多人除了尽可能长寿之外，还有其他优先事项；然而，如果不讨论治疗偏好，他们就有可能接受不符合其目标的治疗。ED 就诊可能提供了一个独特的“可教时刻”，使患者有能力考虑他们对未来医疗保健决策的影响能力。然而，ED 环境的限制带来了具体的挑战，几乎没有研究可以指导在这种环境下治疗患者的临床医生。我们描述了 ED 中目前的临终关怀对话状态，概述了进行这些对话的挑战，并为更好地指导急诊医师进行临终关怀的共同决策推荐了一个研究议程。应用严重疾病沟通的最佳实践可能有助于急诊医师赋予这些患者权力，使他们的未来医疗护理与他们的价值观和目标保持一致。
