Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities

Abstract

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.

Trial registration: ClinicalTrials.gov NCT03208530.

Copyright © 2019 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1.

Conceptual model of goals-of-care conversations in the ED.

Figure 2.

Serious illness trajectories and patients’ or surrogates’ emotional status and awareness of prognosis tendencies.