Difficult Conversations: Outcomes of Emergency Department Nurse-Directed Goals-of-Care Discussions

Area of Science:

• Emergency Medicine
• Palliative Care
• Health Services Research

Background:

• Goals-of-care (GOC) conversations are crucial for aligning medical treatment with patient values, especially for those with serious illnesses.
• Implementing GOC discussions in the emergency department (ED) setting presents unique challenges and opportunities.
• Standardized training for emergency department registered nurses (ED RNs) can facilitate effective GOC conversations.

Purpose of the Study:

• To evaluate the impact of ED RN-led GOC conversations on patient satisfaction, documentation rates, and hospital utilization.
• To assess the completion rates of Physician Orders for Life-Sustaining Treatment (POLST) forms following GOC discussions.
• To analyze changes in subsequent healthcare utilization, including ED visits, hospitalizations, and intensive care unit admissions.

Main Methods:

• A single-center, observational study involving retrospective and prospective data collection.
• ED RNs received standardized GOC conversation training and utilized a structured questionnaire.
• Inclusion criteria focused on patients with advanced chronic conditions (e.g., advanced kidney disease, heart failure, COPD, malignancy).

Main Results:

• High patient satisfaction was reported, with 95-100% rating the experience positively (4/5 or 5/5).
• All enrolled patients (94/94) had their GOC documented in the electronic medical record (EMR).
• POLST form completion increased significantly, with 50% of patients without a prior form completing one during their ED visit. Median ED visits decreased by 15%.

Conclusions:

• ED RN-led GOC conversations are well-received by patients and ensure complete documentation.
• This intervention effectively increases POLST form completion among high-risk patients in the ED.
• The study found no significant adverse effects on subsequent hospitalizations or intensive care unit admissions.