Effect of Emergency Department-Initiated Video-Enhanced Advance Care Planning on Documentation and Goal-Concordant Care: A Randomized Clinical Trial.

BACKGROUND

Advance care planning (ACP) is widely promoted; however, it remains unclear if documentation translates to goal-concordant care aligned with patient values.

OBJECTIVE

To determine whether emergency department-initiated video-enhanced ACP increases documentation and improves goal-concordant care among decedents.

DESIGN

Multicenter, parallel-group randomized trial (2022-2024, follow-up to 2025). Outcome assessors were blinded to assignment.

SETTING

Three emergency departments.

PARTICIPANTS

Adults aged ≥ 65 or 50-64 with serious illness.

INTERVENTIONS: Intervention group (a) viewed an ACP video, (b) had an ACP conversation, and (c) triggered electronic health record provider notification. Controls received usual care.

MAIN MEASURES: Primary outcome was ACP documentation within 3 months. Secondary outcomes included goals-of-care preferences, ACP knowledge (1-5), engagement (1-4), and documentation at 6 months. Goal concordance used a 10-point scale (10 = perfect concordance).

KEY

RESULTS

598 patients (298 intervention, 300 control; mean age 73.5 ± 8.1 years; 53.7% women) were randomized. At 3 months, ACP documentation was significantly higher in the intervention group (45.6% [136/298] vs. 31.3% [94/300]; rate difference [RD] = 14.3%, 95% CI 6.6%-22.0%; P < .001), persisting at 6 months (52.3% vs. 39.3%; RD = 13.0%, 95% CI 5.1%-20.9%; P = .002). ACP knowledge (4.1 vs. 3.1; mean difference [MD] = 1.0, 95% CI 0.9-1.2; P < .001) and engagement (4.1 vs. 3.9; MD = 0.2, 95% CI 0.1-0.3; P = .004) were greater in the intervention group compared to the control. There were no differences in goals-of-care preferences between the two study arms. Among 94 decedents (53 intervention, 41 control), intervention recipients had substantially higher goal-concordance scores (median 10 [IQR 8-10] vs. 7 [IQR 3-10]; P < .001).

CONCLUSIONS

Video-enhanced ACP increased documentation rates. Among decedents, goal-concordance was higher in the intervention group, suggesting ED-initiated ACP may help align care with patient preferences.

TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04931797 (posted June 1, 2021).