Eygnor Jessica K, Allen Jennifer E, Carmichael William G, Best Katie M, Burmeister David B, McLain Katelyn L, Chen Zhe, Stauffer Justin M, Moore Courtney M, Schinelli Anthony, Richardson David M, McCambridge Matthew M, Greenberg Marna R, Friel Timothy J
Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA.
Optimizing Advanced Complex Illness Support (OACIS) / Palliative Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Allentown, USA.
Cureus. 2025 Aug 2;17(8):e89248. doi: 10.7759/cureus.89248. eCollection 2025 Aug.
Background The majority of those aged 65 and older will visit the emergency department (ED) in the last six months of life. Knowing a patient's goals of care is important, and existing medical records do not always represent them well. We set out to determine the baseline availability of advance directives and goals of treatment in those ED patients at increased risk for mortality. Methods This prospective cohort study included a sample of adult ED patients who had a mortality predictor by an End-of-Life (EOL) Deterioration Index-guided electronic best practice advisory (BPA) or admission to any of the network's intensive care units (ICU). Electronic medical record (EMR) abstraction was used to evaluate for documentation of healthcare proxy, healthcare power of attorney (POA), living will, advance care plans, or physician orders for life-sustaining treatment (POLST). Results A total of 9,321 patient encounters, representing 7,204 unique patients, were included in the analyzed sample. Most patients' charts lacked advance care planning documentation such as healthcare proxy (98.7%, N=9200), healthcare POA (93.0%, N=8665), living will (94.6%, N=8816), advance care planning status (66.8%, N=6226), and POLST (95.8%, N=8928). Overall, urban sites had a larger percentage of encounters in which a high-risk patient might benefit from advance care planning discussions than rural sites. Females had a higher percentage of documentation across all variables of goals of care, with significant differences in healthcare POA (p < 0.001), advance directives (p < 0.001), and POLST (p = 0.008). Conclusions The majority of patients with a higher risk for mortality, as indicated by an EOL Deterioration Index-guided BPA or hospital ICU admission, do not have documentation in the EMR across all variables of goals of care.
大多数65岁及以上的老年人在生命的最后六个月会前往急诊科（ED）就诊。了解患者的医疗护理目标很重要，但现有的病历并不总能很好地体现这些目标。我们着手确定那些死亡风险增加的急诊科患者预先指示和治疗目标的基线可及性。方法：这项前瞻性队列研究纳入了成年急诊科患者样本，这些患者通过临终（EOL）恶化指数指导的电子最佳实践建议（BPA）或入住网络内的任何重症监护病房（ICU）具有死亡预测指标。采用电子病历（EMR）摘要来评估医疗保健代理人、医疗保健授权书（POA）、生前遗嘱、预先护理计划或维持生命治疗的医生医嘱（POLST）的记录情况。结果：分析样本共纳入9321次患者就诊，代表7204名独特患者。大多数患者的病历缺乏预先护理计划记录，如医疗保健代理人（98.7%，N = 9200）、医疗保健POA（93.0%，N = 8665）、生前遗嘱（94.6%，N = 8816）、预先护理计划状态（66.8%，N = 6226）和POLST（95.8%，N = 8928）。总体而言，城市地区中高风险患者可能从预先护理计划讨论中受益的就诊比例高于农村地区。女性在所有护理目标变量的记录比例更高，在医疗保健POA（p < 0.001）、预先指示（p < 0.001）和POLST（p = 0.008）方面存在显著差异。结论：以EOL恶化指数指导的BPA或医院ICU入院表明，大多数死亡风险较高的患者在电子病历中没有所有护理目标变量的记录。
