Effect of a multi-component palliative care intervention on goals of care discussions for critical patients in the emergency department.

Goals of care (GOC) discussions are vital to understanding patients' values and preferences during serious illness, but they occur infrequently during Emergency Department (ED) care. We report a single site sub-study of a stepped wedge pragmatic trial of a multi-component intervention of primary palliative care in the ED (PRIM-ER), focused on GOC conversations. A retrospective cohort study of ED patients who either died or had a referral to hospice within 48 h or were admitted to an Intensive Care Unit (ICU). The PRIM-ER intervention consisted of: (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback. The pre-intervention period was September 2018-August 2019 and the post-intervention period was November 2019-April 2020. Of the 153 included cases, 76 (49.7%) were pre-intervention and 77 (50.3%) were post-intervention. Only 6.5% (n = 10) had a Do Not Resuscitate order prior to the ED visit. The intervention did not change the proportion of patients receiving a GOC conversation in the ED (38.2% vs 40.3%, χ2 p = 0.79). Presenting with a cancer-related complaint (OR 12.9, 95% CI 4.15-39.92) or a respiratory emergency (OR 3.02, 95% CI 0.15-0.81) were associated with increased odds of a GOC conversation occurring. Of the 60 GOC conversations that occurred, 76.7% (n = 46) resulted in a change in code status, patient care plans, hospice, or updated advance care planning documents. While the intervention did not increase this secondary outcome of GOC conversations, the discussions that did occur frequently impacted ED care.