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Communication Surrounding Treatment Preferences for Older Adults With Dementia During Emergency Medical Services
Lauren R Pollack1,2, Danae G Dotolo1,2, Anna L Condella1,2,3
1Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA.
Background:
Emergency Medical Services (EMS) providers, capable of rapidly delivering life-prolonging interventions, are often first to respond to acute health concerns for older adults in the United States. Prior work has shown a preference among many people with dementia for comfort-focused care near end-of-life. People with dementia frequently use EMS; however, little is known about communication surrounding treatment preferences during EMS response for this group.
Methods:
We conducted a qualitative content analysis of EMS incident reports for older adults with dementia transported to two urban academic hospitals (2011-2021). We identified eligible patients in the hospital electronic health record applying the following criteria: age ≥ 65, diagnosis code indicating dementia, assessment by EMS, hospitalization between 2011 and 2021, and National Early Warning Score ≥ 7 indicating critical illness. We characterized the frequency and content of documented patient treatment preferences in EMS incident reports and identified barriers and facilitators to communication about treatment preferences or goal-concordant care.
Results:
We reviewed incident reports for 171 patients with a median age of 82 (IQR 12) years. About half (51%) of the patients were residing in nursing homes. A minority (23%) of the patients were described as able to communicate needs, and only 24% had a family member or friend present at the time of EMS assessment. Treatment preferences were mentioned in 27% of the reports. EMS providers documented barriers to communication or delivery of goal-concordant care in nursing home settings that included difficulty obtaining information from professional caregivers, receiving secondhand information, and variable role expectations. Goal-concordant care was facilitated in these settings when EMS providers spoke directly with patients' family members by telephone.
Conclusions:
EMS providers treating critically ill older adults with dementia face challenges that may hinder their ability to elicit treatment preferences, in particular when responding to calls from professional caregivers. Direct communication with surrogate decision-makers may facilitate goal-concordant care.
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