What is the ideal way to hold goals of care conversations in Emergency Departments for acutely unwell patients approaching their end of life?

Ms Jennifer Hanning1,2, Ms Erin O’Callaghan1
1Cabrini Emergency Department, Malvern, Australia, 2University of Melbourne, Parkville, Australia

Background: Improving end-of-life care is a high priority in Emergency Medicine. Goals-of-care conversations enable patients to discuss preferences and values before making a shared decision about aims of care with their healthcare provider. These conversations have significant benefits for patients, families, and hospital staff and systems, such as reducing inappropriate CPR and time spent in hospital towards end-of-life. However, there is little evidence on this topic in Emergency Medicine. We searched the literature for how best to have these conversations in EDs and tested a new patient-centred Goals-of-Care form.
Methods:  The systematic review followed PRISMA guidelines, finding articles related to Goals-of-Care conversations in acutely unwell patients. In the form evaluation, trial double-sided Goals-of-Care/NFCPR forms replaced usual NFCPR documentation in the ED. Data on form usage, patient demographics and outcomes including hospital length of stay and 6-mortality were collected. Doctors were interviewed regarding satisfaction with the form, suggestions for improvements, and perspectives on Goals-of-Care discussions in EDs.
Results: Very few articles specifically address Goals-of-Care conversations in EDs. We discovered that there is no consensus on the meaning or purpose of Goals-of-Care conversations in Emergency Medicine, and little evidence for when or how they should occur. Involving nursing staff has benefits but their role in conversations is not well defined. 88% of doctors valued having a Goals-of-Care form, but some did not use all sections, and opinions were varied regarding ideal format and content.
Conclusions: There is almost no evidence on Goals-of-Care conversations in EDs. Use of a form to guide or document a discussion is welcomed, but ideal content of the form was not determined. More work is required to determine the purpose and content of these conversations in EDs and how they should be documented to align the needs of patients and healthcare workers.

Jennifer Hanning is a final year medical student who completed a 6 month research term in the Cabrini Emergency Department. She has a Master of Public Health and is interested in a wide range of issues including emergency medicine and women’s health. She previously worked as an Emergency medical scribe in the Victorian multi-centre scribe trial.