2 3 During the last few months of life, many older adults receive care that is discordant with their preferences, 4 increases suffering, and disrupts closure and grieving. The process of advance care planning (ACP) helps 5 patients have control over their end-of-life care by empowering patients to define and document what care they 6 would like to receive while they still have the cognitive and physical abilities to consider and express these 7 preferences. ACP improves patient and family satisfaction with the dying process, increases the likelihood that 8 patients receive the care they want, and reduces healthcare expenditures. Unfortunately, few older adults have 9 completed ACP and even fewer have documented their end-of-life care preferences in a way that is accessible 10 in a timely manner to medical providers. In a recent Institute of Medicine report on Death and Dying in America, 11 increasing ACP among older adults was identified as a major public priority. Primary care providers, who typically 12 have long-term relationships with patients and understand the details of their medical condition, are well 13 positioned to have end-of-life care conversations. Unfortunately, for several reasons these conversations often 14 do not occur: primary providers don?t want patients to think they?ve given up hope; patients think they are too 15 healthy to benefit from these conversations; and educating patients about end-of-life options takes time. U.S. 16 emergency department (ED) visits provide access to a large number of older adults with advanced illness who 17 are likely to benefit from ACP and provide a unique and important opportunity to overcome these barriers to 18 ACP. Specifically, emergency providers are unlikely to fear undermining a long-term relationship with the patient, 19 older adults who are receiving ED care are unlikely to think they are too healthy to benefit from ACP, and there 20 is ample opportunity during the ED visit to educate patients and initiate a conversation about end-of-life care 21 preferences. The overarching goal of this project is to develop evidence to support the use of an ED-based 22 intervention to promote ACP. We propose a randomized controlled trial of 900 older adults receiving care at 23 three U.S. EDs. Patients receiving the intervention will watch a 5-minute certified video decision aid about ACP 24 and have a structured conversation with a social worker about their values and preferences. The social worker 25 will then send a secure electronic message to the patient?s primary provider sharing with them the patient?s initial 26 preferences and providing instructions as to how to document the patient?s preferences in a manner that is widely 27 accessible to the patient?s medical providers. Following the clinical model of shared decision making, patients 28 will be encouraged by the social worker to deliberate further on their preferences and then have an informed 29 conversation with their primary provider or admitting physician regarding care preferences. Outcomes will include 30 documentation of ACP conversations and preferences, agreement between expressed and documented 31 preferences, and hospital days assessed 3 and 6 months after the ED visit. The results of this study will establish 32 the efficacy of this intervention and provide information to support and inform implementation.
Discussions between patients and physicians about end-of-life care preferences allow older adults to maintain control over their medical care at the end of life and reduce unwanted medical interventions. The emergency department visit provides a unique opportunity to promote these discussions among patients likely to benefit from these conversations. The proposed study will test an intervention which combines a certified video decision aid, a semi-structured conversation with a social worker, and secure electronic communication with the patient's primary provider and admitting physician to support end-of-life care discussions for older adults receiving care in the emergency department.
