A qualitative assessment of a guide for goals of care conversations in the ED

High quality goals of care (GOC) conversations are notoriously difficult to have in the emergency department (ED). Minimal training, constrained timelines and critical illness are among the barriers often identified [ ]. There has been considerable research growth in this area with studies investigating different interventions, including: embedded palliative care teams [ ], nurse-directed conversations [ ], social worker-led conversations [ ], and resident training [ ]. Outcomes of these studies include feasibility, acceptability, documentation of conversations, comfort with the material, consideration of GOC as an ED responsibility, changes in rates of hospitalization and intensive care unit utilization, and benefits to patient care.

There is a gap between the patient preference for the conversation to occur with primary care and the urgent need when patients present to the ED. Hartanto et al [ ] identified when there are changes in condition that advance care planning was appropriate – the ED is often the setting where changes in condition are detected, and an appropriate time to revisit or elicit patient wishes and preferences. Despite patient perceptions of GOC conversations being assessed in multiple settings [ ], the ED is infrequently included in these studies.

With stakeholder input, we created a conversation tool and iteratively refined it based on patient and care team feedback [ ]. The purpose of this study was to explore acceptability, obtain perspectives regarding the use of the tool, understand how GOC conversations are received in the ED, and to identify ways in which the experience is altered by conversation tool use.

The study setting is an academic ED that is part of a quaternary care hospital, Level 1 Trauma Center serving a largely rural catchment area. Annual ED volumes are 77,000 patients per year with 38% of the visits by patients age 60 and older. We aimed to include patients who would most benefit from a GOC conversation including those with an Elders Risk Assessment (ERA) Score [ ] of ≥16 [ ], age ≥ 60 with two or more hospitalizations in the last 6 months, ability to engage in informed consent, and medical stability.

Through structured interviews and surveys, we conducted this pre-planned analysis of qualitative feedback received from patients and their caregivers regarding their experience, use, and design of a GOC conversation tool. We used a constructivist paradigm to frame our analysis. Data included verbal comments that were transcribed by study staff and written responses from patients. Qualitative responses to 12 questions were reviewed by two independent raters who labeled the responses as “positive”, “neutral” or “negative”. Themes were identified and grouped. Disagreement was reconciled by discussion and consensus. Raters were blinded to patient and clinician identifying data. We followed the Standards for Reporting Qualitative Research [ ].

A total of 258 responses were submitted. There were 155 (60.1%) identified as “positive”, 79 (30.6%) as “neutral” and 26 (10.1%) as “negative”. Themes identified included: timing/efficiency on the use of the tool, design and tool content, conversation process, barriers, and improvements. Most of the themes had mostly positive comments, except for “barriers” which was 22% positive, 28% negative. Sixty-eight percent of responses were favorable when asked how the conversation went with the doctor, and most patients would like to use this tool again. Comments remarked on new ways of thinking about end-of-life care, focus on symptom control, and reflection on personal values. Among the responses to “what surprised you about the conversation?” included a family member who was surprised to hear the patient would not want resuscitative measures, patients who had not participated in conversations using tools in the past and expressed appreciation for the images and cues, and for the prompt to think about GOC at end-of-life. The one negative response to this question was a patient that had hoped that the conversation would be more in depth than it was.

Five themes were identified: time/efficiency on the use of the tool, design including drawings and organization of the tool, barriers to the conversation process, and improvements to the tool and conversation ( Table 1 ). Most (94%) of the comments related to improvements were positive, and generally related to ways in which the conversation and use of the tool were an improvement over prior experiences.

Table 1

Questions and associated themes.

	time/efficiency (+)	time/efficiency (−)	all time/efficiency	design (+)	design (−)	all design	conversation (+)	conversation (−)	all conversation	barriers (+)	barriers (−)	all barriers	improvements (+)	all improvements
How do you think your conversation went with your doctor?	0	0	0	3	0	3	4	0	6	2	0	5	0	0
What surprised you during the conversation?	0	0	0	3	0	3	4	1	8	0	1	1	4	5
What frustrated you during the conversation?	0	0	0	1	0	1	1	0	1	0	0	0	2	2
How did you like this conversation tool as part of your conversation with the doctor today?	1	0	2	7	2	11	4	0	4	0	0	1	6	6
What did you find helpful about this tool?	1	0	1	10	0	11	8	1	9	1	1	2	5	5
What did you find unhelpful about this tool?	0	1	1	1	5	7	0	2	2	1	3	4	0	0
Are there things that you would have liked to have brought up during this conversation but didn’t? Why?	0	0	1	0	0	0	1	2	3	0	0	4	0	0
How was this different than usual conversations with doctors?	2	1	3	1	0	1	11	0	14	0	0	1	8	9
Would you like for your doctor to use this tool again?	0	0	0	0	0	0	0	0	0	0	0	0	1	1
Would you like for other doctors to use a tool like this for other topics?	1	0	1	2	0	2	1	0	1	0	0	0	0	0
Other question(s)? If so, provide question(s) and patient’s answer(s).	0	1	1	1	0	1	0	0	0	0	0	0	1	1
Do you have any final comments or questions?	0	0	0	2	0	2	2	0	2	0	0	0	2	2