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Ann Emerg Med. 2019 Aug;74(2):276-284. doi: 10.1016/j.annemergmed.2019.01.003. Epub 2019 Feb 13.

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

Author information

1
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA. Electronic address: kouchi@partners.org.
2
Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA; Department of Emergency Medicine, Harvard Medical School, Boston, MA.
3
Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
4
Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA.
5
The Brief Negotiated Interview Active Referral to Treatment Institute, Boston University School of Public Health, and the Department of Emergency Medicine, Boston University School of Medicine, Boston, MA.
6
Department of Medicine, University of California, San Francisco, CA.
7
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
8
Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Serious Illness Care Program, Ariadne Labs, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA.

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.

PMID:
30770207
PMCID:
PMC6714052
[Available on 2020-08-01]
DOI:
10.1016/j.annemergmed.2019.01.003

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