Review article: Goals‐of‐care discussions for adult patients nearing end of life in emergency departments: A systematic review

Abstract

Goals-of-care discussions at end-oflife are associated with increased patient satisfaction and reduced treatment burdens, reduced family and healthcare worker distress and healthcare costs, while achieving equal life-expectancy. It is unclear how goals-of-care discussions should occur. The objective of the study was to determine which patients could benefit, requirements, content, documentation, and harms and benefits of emergency medicine goals-of-care discussions. We sought primary evidence on goals-of-care discussions in EDs with adult patients nearing end-oflife, published in English after 1989. Data sources included Medline, Embase, PsycINFO, CINAHL, Web of Science and reference lists of included articles. One thousand nine hundred and twenty abstracts were screened, five articles selected. There was no consensus on the meaning of goals-of-care, which is often confused with advanced care planning and treatment limitation. Emergency clinicians can identify most patients needing discussions following training. There was no evidence for how to involve stakeholders, nor how to adapt conversations to meet cultural and linguistically diverse needs. Expert panels have suggested requirements and content for conversations with little supporting evidence. There was no evidence for how emergency conversations differ to those in other settings, nor for harms or benefits for holding goals-of-care conversations in EDs. Increased ED goals-of-care conversations increased hospice referral and reduced in-patient admissions. Most studies were of moderate quality only, outcomes were not standardised and sample sizes were small. 'Goals-of-care' is used inconsistently across the literature. This is the first systematic review regarding goals-of-care discussions in EDs. Further research is needed on all aspects of these conversations.

Review article: End‐of‐life care for older people in the emergency department: A scoping review

“…Despite a focus on people at EOL, most studies did not include an EOL definition, although EOL care is well defined in policies and guidelines . This finding aligns with a recent systematic review of goals of care discussion for adult patients nearing EOL in the ED which reported that there is no common understanding of the meaning, purposed or desired outcomes of these conversations in the ED and that the concept was also poorly defined . Authors recommended that a standardised definitions and outcome measures are needed in this area .…”

“…This finding aligns with a recent systematic review of goals of care discussion for adult patients nearing EOL in the ED which reported that there is no common understanding of the meaning, purposed or desired outcomes of these conversations in the ED and that the concept was also poorly defined . Authors recommended that a standardised definitions and outcome measures are needed in this area . Furthermore, cultural factors potentially influencing EOL care delivery were not evident in the articles reviewed.…”

Evaluation of an End-of-Life Essentials Online Education Module on Chronic Complex Illness End-of-Life Care

“…It is often used to cover discussions about treatment intent and planning end stage care with patients [27]. The term is often confused with Advance Care Planning (ACP) or discussions that relate to treatment limitation [28], so establishing a common understanding of what discussing 'goals of care' entails is important [22]. Goals of care conversations are usually driven by the patient's and family's hopes, fears, expectations, and preferences for information, with treatment and care plan decisions often based on discussion and consideration of patient comfort and quality of life [27].…”

Risky Behavior: Hospital Transfers Associated with Early Mortality and Rates of Goals of Care Discussions

“…Based on prior research on the outcomes of IHT patients and the effects of GoC discussions we suspect that early delivery of prognostic information and GoC discussions may have prevented some of these transfers from occurring, thereby possibly improving patient and family satisfaction, reducing treatment burden, and reducing costs. [16][17][18][19][20][21] The majority of patients in this study came from ED settings. Barriers to GoC discussions occurring in ED settings likely include time limitations, provider comfort level with these discussions, lack of training in conducting GoC discussions, and availability of palliative care resources for potential care transitions.…”