Serious illness conversations are discussions between patients with advanced illness and their clinicians that focus on their values, goals, and priorities related to their health care. 1 As part of a comprehensive care plan, serious illness conversations can lead to well-informed shared decision making and improved quality of life at the end of life. 2 For seriously ill older adults (expected prognosis of < 1 year), these conversations may be associated with lower rates of in-hospital death, less aggressive medical care at the end of life, earlier hospice referrals, increased peacefulness, and a greater likelihood to have end-of-life wishes known and followed. 2–9 Furthermore, one study reported that patients who had documented serious illness conversations could reduce expenses by 36%, with each patient saving $1,041 on average during their last week of life. 10 Experts recognize that earlier serious illness conversations may be among the keys to “bending the cost curve” for health care. 11 Yet only 37% of seriously ill older adults have these conversations with their physicians, 2 on average 33 days before death. 12
Emergency departments (ED) may serve as an ideal setting to engage seriously ill, yet clinically stable, older adults who may benefit from serious illness conversations. During the last six months of life, 75% of older adults visit the ED.13 ED visits are inflection points in these patients’ illness trajectories, signaling a more rapid rate of decline.14–16 Furthermore, seriously ill older adults have a 24–48% mortality following these ED visits.17–19 More than 70% of these patients express priorities focused on comfort and quality of life rather than life extension,20 yet a systematic review revealed that 56–99% do not possess advance directives in the ED,21 and many are at risk of receiving care that does not align with their goals.22 To leverage this opportune moment in the ED, we developed and tested a behavioral intervention to engage seriously ill older adults in serious illness conversations (ED GOAL) to overcome the known barriers to serious illness conversations in this setting (e.g., time constraints, limited privacy, uncertainty in patients’ awareness of their illness).23 Guided by the Social Cognitive Theory24 and modeled from previously successful ED-based behavioral interventions25–30 using the Transtheoretical Model,31 ED GOAL consists of a short, motivational interview that aims to prime patients to discuss their goals of care with their outpatient clinicians rather than triggering a more time-consuming, sensitive conversation in the time-pressured ED. In a small pilot of ED physicians (and advance practice clinicians) speaking with 23 seriously ill older adults, 82% found ED GOAL acceptable and stated that it helped them engage in conversations about their goals for future care with their outpatient clinicians. Yet, emergency physicians were often interrupted; thus, limiting ED GOAL’s implementation.32 ED nurses suggested that a specially-trained, nurse consultation model would result in improved efficacy because motivational interviewing is within their scope of practice.33–38 In a feasibility study of trained study nurses who enrolled and conducted the intervention with 76 patients., the self-reported readiness to engage with outpatient physicians increased from 2.8 to 3.3 on a 5-point Likert scale (p = 0.008) and 16% of the patients reported that they talked to their primary outpatient clinician about their future care at one month after the intervention. Most participants (62%) reported that after ED GOAL they felt “completely” heard and understood by the study nurse about what they would want in medical care if they were to get sicker, compared to only 15% who felt this way with their outpatient clinicians. In addition, 16%, 25%, and 33% of participants had a new documentation of serious illness conversations with their outpatient clinicians at one, three, and six months, respectively; suggesting that ED GOAL successfully led to patient-clinician communication about goals of care in the outpatient setting. (ClinicalTrials.gov identifier NCT04730986, under peer review).
Despite these promising findings from observational studies, the efficacy of ED GOAL has not been established in a randomized study. Therefore, in this study protocol, we describe a two-armed, parallel, single-blinded, randomized controlled trial of seriously ill older adults in three EDs in Boston, MA. We will compare the ED GOAL intervention group to a control group receiving usual care. The objectives of this study are: i) to test, in a randomized controlled design, the effect of ED GOAL administered by trained nurses on patient- and caregiver-reported ACP engagement one month after leaving the ED (primary outcome) and ii) to evaluate the impact of ED GOAL on self-reported completion of serious illness conversations, new, documented serious illness conversations in the electronic medical records (EMR), quality of communication, health care utilization, and survival.