Serious Illness Conversations in the Emergency Department for Older Adults With Advanced Illnesses: A Randomized Clinical Trial.

IMPORTANCE

Conversations between seriously ill patients and clinicians about values and goals (ie, serious illness conversations [SICs]) can lead to patient-centered care toward the end of life. However, many patients have not had SICs when arriving in the emergency department (ED) and are at risk of receiving undesired care.

OBJECTIVE

To determine the effect of an ED-based, multimodal SIC intervention (known as ED GOAL) compared with usual care on patient-reported engagement in advance care planning (ACP) and clinician-documented SICs after leaving the ED.

DESIGN, SETTING, AND PARTICIPANTS: This 2-armed, 1:1, parallel-design randomized clinical trial was conducted at 3 participating EDs (2 academic medical centers and 1 community hospital) in Boston, Massachusetts, within a single health system between March 1, 2022, and July 1, 2024, with a follow-up duration of 6 months. 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. Patients with documented goals for medical care or physician orders in the last 3 months in medical records or deemed clinically inappropriate by the treating ED team were excluded.

INTERVENTION

SIC-trained research nurses conducted (1) a motivational interview about SICs, (2) a structured SIC, and (3) communication priming for the patients and their primary clinicians to reinitiate SICs on a tablet computer in the ED or within 1 week after leaving the ED.

MAIN OUTCOMES AND MEASURES

The primary outcome was a validated survey of patient-reported engagement in ACP at 1 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.

RESULTS

A total of 141 patients (mean [SD] age, 66.7 [9.2] years; 73 [51.8%] female), predominantly diagnosed with metastatic cancer (85 [60.3%]), were enrolled and randomized to the intervention (n = 70) or usual care (n = 71). At 1 month, no difference was observed in patient-reported engagement in ACP (mean [SD] score, 3.32 [1.28] for control vs 3.37 [1.07] for intervention; maximum possible score, 5.00; P = .58), yet 12 patients in the intervention group (17.1%) discussed care preferences with their physicians compared with 5 (7.0%) control group patients (P = .07). Medical record documentation of end-of-life values and goals was significantly higher in the intervention group at 3 months (17 [24.3%] vs 7 [9.9%]; P = .03) and 6 months (22 [31.4%] vs 9 [12.7%]; P =  .008).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of seriously ill older adults in the ED, while a nurse-led SIC intervention did not significantly improve patient-reported engagement in ACP, it did increase clinician-documented SICs in the medical records. ED visits may serve as a critical access point to enhance SICs for seriously ill yet clinically stable older adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05209880.