Shiozawa Youkie, Morton Saaya, Shirai Nanako, Oelschlager Hannah, Kiernat Lucy, Chary Anita N, Revette Anna C, Haimovich Adrian, Desai Smit, Chang Kai-Wei, Liu Shan W, Kennedy Maura, Schonberg Mara A, Ouchi Kei
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Harvard Medical School, Boston, Massachusetts, USA.
Acad Emerg Med. 2025 Jul 29. doi: 10.1111/acem.70109.
Emergency department (ED) visits offer opportunities for seriously ill patients to formulate future medical care goals, yet ED clinicians lack practical strategies for these conversations. ED GOAL, a behavioral intervention, engages seriously ill yet clinically stable older adults in the ED to address advance care planning (ACP) with their outpatient clinicians. In a randomized trial, goals-of-care documentation was significantly higher in the intervention group compared to controls after three (24.3% vs. 9.9%, p = 0.03) and 6 months (31.4% vs. 12.7%, p < 0.01). This study is a sub-analysis to learn about intervention arm participants' perceived benefits and obstacles of the intervention.
We conducted semi-structured interviews between October 2022 and August 2024 (N = 52) with intervention-arm patients aged 50+ years at three hospitals in Boston, Massachusetts. Using rapid qualitative analyses, we identified themes in intervention-arm participants' comments to open-ended questions about the intervention's benefits and obstacles to continue ACP outside the ED.
Of 70 intervention-arm participants, 52 completed interviews, of which two were surrogates. ED GOAL motivated most patients to initiate ACP with outpatient clinicians and loved ones and improved the quality of conversations by clarifying patients' wishes and improving patient-clinician relations. Barriers to continuing ACP were the lack of clinician availability and patient/surrogate readiness. Those with clear care goals found the intervention less useful yet harmless.
The intervention provided participants with insights into actionable ACP steps. To address the lack of clinician availability, these conversations may be completed by non-physician clinicians or through non-personnel resources. Better tailored ACP interventions may improve patients' readiness.
ClinicalTrials.gov identifier: NCT05209880.
急诊科就诊为重症患者提供了制定未来医疗护理目标的机会，但急诊科临床医生缺乏进行此类谈话的实用策略。“急诊科目标”（ED GOAL）是一种行为干预措施，促使急诊科病情严重但临床状况稳定的老年人与他们的门诊临床医生讨论预先医疗护理计划（ACP）。在一项随机试验中，干预组的护理目标记录在3个月（24.3% 对9.9%，p = 0.03）和6个月（31.4% 对12.7%，p < 0.01）时显著高于对照组。本研究是一项子分析，旨在了解干预组参与者对该干预措施的感知益处和障碍。
我们在2022年10月至2024年8月期间，对马萨诸塞州波士顿三家医院50岁及以上的干预组患者进行了半结构化访谈（N = 52）。通过快速定性分析，我们在干预组参与者对关于该干预措施的益处以及在急诊科之外继续进行ACP的障碍的开放式问题的评论中确定了主题。
在70名干预组参与者中，52人完成了访谈，其中两人是代理人。“急诊科目标”促使大多数患者与门诊临床医生和亲人开始讨论ACP，并通过明确患者意愿和改善医患关系提高了谈话质量。继续进行ACP的障碍是临床医生时间有限以及患者/代理人准备不足。那些有明确护理目标的人发现该干预措施用处较小但并无害处。
该干预措施为参与者提供了关于可采取行动的ACP步骤的见解。为解决临床医生时间有限的问题，这些谈话可由非医生临床医生或通过非人力资源完成。更有针对性的ACP干预措施可能会提高患者的准备程度。
ClinicalTrials.gov标识符：NCT05209880。
