KS-012049 eCQ 11-2 Newsletter

Emergency Department Intervention Aims to Engage Older Adults to Consider Serious Illness Conversations

Abrief, structured intervention aimed at empowering seriously ill older adults presenting to the emergency department (ED) to understand the importance of identifying their care goals and planning their future medical care was deemed acceptable by nearly three-quarters of participating patients, who found it to be appropriate, reasonable, and understandable. “Clinicians in the ED urgently need a practical intervention to engage older adults in serious illness conversations,” write the authors of a report published in the Journal of PalliativeMedicine. Their intervention is “tailored to allow busy emergency physicians to engage patients in addressing an important chronic care issue without conducting a time-consuming, sensitive conversation in the time-pressured ED environment.” Boston researchers adapted an established, brief negotiated interview (BNI) intervention designed for patients with alcohol dependence to fit the needs of seriously ill patients. The scripted interview guides clinicians in creating patient engagement and trust by showing respect for patient autonomy and compassion- ate curiosity. The interventionwas refined through a series of 16mock clinical encounters of ED clinicians (11 attending emergency physicians; three physician assistants; male, 71%) and seven members of the facility’s patient/family advisory council (mean age, 68 years; male, 43%) acting in the role of patients during the scenarios. EXAMPLES OF THE REFINED SCRIPT INCLUDE: • Focus on goals of care, specifically and respectfully. “Because you have (serious illness) and you are in the ED, I am worried that your disease may progress further. This is a really good time to think together about what kind of care is right for you if you get sicker. Can I help you talk to your doctor about what is important in your care when you get sicker?” • Address follow-up appointment following ED visit. “I’d like to talk about what’s ahead after leaving the ED and seeing your outpatient doctor to share what is important in your care if you get sicker.” The team then tested the resulting six-step intervention at an urban tertiary medical center’s ED by administering it in the fall of 2017 to 23 patients (mean age, 76 years; female, 65%; metastatic cancer, 43%) who had serious illness or whose treating ED clini- cian answered “No” to the Surprise Question (“Would you be sur- prised if this patient died in the next 12 months?”). Following the intervention, researchers conducted one-on-one interviews with the patient participants to assess the acceptability of the intervention. PATIENTS’ RESPONSE TO THE INTERVENTION • Most patient participants (73.9%) gave a positive assessment of the intervention, approving of the clinicians’ gentle and com- forting approach and reporting they experienced no negative emotions during the encounter.

• A majority of participants expressed positive attitudes toward advance care planning.Whether or not they felt ready to engage in care planning, most said they comprehended its importance. • Most participants expressed appreciation for being given an impetus to think about and discuss their future care and for receiving suggested questions they could ask their primary physicians. It was “like a wakeup call,” reported one patient, “to sit down with my doctor to discuss these issues.” Prior research has shown that between 56% and 99% of older adults have not completed an advance directive when presenting to the ED, note the authors. Not having previously considered and documented their preferences for future medical care puts these patients at risk of receiving care that does not alignwith their goals. “The BNI intervention uses clinicians’ empathetic, reflective listening to elicit behavior change by helping patients appreciate the discrepancy between their goals and current behavior (e.g., having no advance directive) and ultimately resolve this ambiva- lence,” write the authors. Although emergency physicians are aware that encounters with older, seriously ill patients provide an opportunity to discuss care wishes, barriers intrinsic to the ED setting “make it very difficult to conduct effective, in-depth conversations,” note the authors. BARRIERS TO ED CARE PLANNING INCLUDE • The time-pressed ED environment • The acuity of many patients’ medical needs • Lack of training in serious illness communication in this setting “Our carefully developed, structured intervention represents a promising tool that respects the time demands of the setting... and the imperative to activate patients to seek conversation with their primary outpatient clinician,” write the authors. “Our study is the first to adapt the BNI concept in the context of serious ill- ness conversations.” The authors suggest that further study of the feasibility and efficacy of the intervention is needed, along with testing of pos- sible modifications, e.g., for patients with dementia or for when caregivers wish to be included, and they plan to present follow-up outcome data from their future studies. The full ED intervention script is available online as supple- mentary material to the report. Source: “Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department,” Journal of Palliative Medicine; Epub ahead of print, November 12, 2018; DOI: 1089/jpm.2018.0360. Ouchi K, Block SD, et al; Department of Emergency Medicine, Brigham andWomen’s Hospital; Department of Emergency Medicine, Harvard Medical School; Serious Illness Care Program, Ariadne Labs; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Emergency Medicine, Boston University School of Medicine; Division of Palliative Medicine, Department of Medicine, and Department of Psychiatry, Brigham and Women’s Hospital; all in Boston.

Volume 11, Issue 2

Page 2