For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

The need for palliative and hospice care in the ED is increasing, requiring that emergency physicians be familiar with palliative and hospice care and competent in the delivery of rapid symptom management in patients with severe and life-limiting disease.

Objective: This study aims to evaluate the potential impact of addressing goals-of-care (GOC) with selected patients in the emergency department (ED), GOC documentation, hospital utilization, and patient satisfaction. Method: This is a single-center, retrospective, and prospective, observational convenience-sample study. ED registered nurses (ED RNs) received standardized GOC conversation training. Their selection criteria included a selection interview, a minimum of 3 years of ED clinical experience, and current employment in the ED. ED RNs used a standardized GOC questionnaire. Patient inclusion criteria included age ≥18 years and one or more of the following: chronic kidney disease ≥ stage III, congestive heart failure with an ejection fraction ≤ 40%, chronic obstructive pulmonary disease with home oxygen use, and/or malignancy with metastasis. GOC conversations were recorded in the electronic medical record (EMR). Physician Orders for Life-Sustaining Treatment (POLST) forms were completed as appropriate. Select individual patient data for the 12 months prior to the conversation were compared with the following 12 months. Results: Over 6 months, 94 of 133 patients who were approached consented to the GOC discussion with the RN. All 94 enrolled patients had their GOC recorded into the EMR. One-third already had a completed POLST form prior to ED arrival. 50% without a POLST on ED arrival left with a completed POLST. Eighty-four patients survived the index visit and 46 patients survived to study completion. Patient satisfaction with the interaction was high: In the cohort who survived past the index visit, 95% rated their experience at 4/5 or 5/5 (Likert scale, 5: strongly agree, 1: strongly disagree). In the survival-to-study completion cohort, 100% rated their experience as 4/5 or 5/5. Subsequent median ED visits decreased by 15% (1.0-4.0 interquartile range). There were no statistically significant changes in hospitalizations (both decreased by 25%, 0-3.0) or intensive care unit admissions (0%, 0-0). Conclusions: An ED RN-led GOC conversation had high patient satisfaction and 100% GOC documentation in the EMR. There was a significant increase in ED POLST form completion. There were no significant changes noted in subsequent hospitalizations, length of hospitalization, or intensive care unit utilization.

BackgroundPatients' goals of care (GOC), which direct end-of-life clinical decision-making, should be established in conjunction with their primary physician when they are well. However, these discussions are often left for when critical intervention is needed in the Emergency Department, and this has been exacerbated in the new context of the current coronavirus disease 2019 pandemic. Establishing effective, formal training for Emergency Medicine (EM) residents to successfully carry out these conversations and potentially improve patient care is needed. MethodologyA physician dual-certified in Emergency Medicine and Palliative Care developed a virtual course on best practices in determining GOC for EM residents. It occurred for one hour during resident didactic conference and all residents who attended were included. A survey was sent to all participants to assess the success of the course's content and method of delivery. ResultsOf the 39 residents who participated, 18 (46%) completed the survey. The majority (94%) agreed the course helped close knowledge gaps and increased comfort in carrying out these discussions and 100% planned to incorporate these learning points into practice. A smaller majority (61%) thought the virtual platform was an effective method of delivery and 61% felt the breakout rooms helped with learning retention. Open-ended comments reflected learners' desire for more of this content, suggestions to augment with simulation, as well as technical difficulties experienced. ConclusionsThis course helped EM residents identify and close knowledge gaps in determining patients' GOC who plan to incorporate what they learned into their clinical practice. Next steps in validating the course include seeking more pointed feedback of the virtual format and assessing its effects over broader audiences after making feedback-focused adjustments to its content and delivery.