Project Summary / Abstract The majority (75%) of older adults with serious illnesses visit the Emergency Department (ED) during the last six months of life. ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Many of these patients have not formulated and communicated their goals for end-of-life care, and the majority (56 to 99%) of older patients do not have advance directives available at the time of ED presentation. Most of these patients have priorities other than simply to live as long as possible, yet without alternative plans in place, they may receive aggressive care that does not align with their goals. Therefore, the ED provides a point in time and a location to identify and empower patients who would benefit from formulating and communicating their goals for future medical care. Emergency medicine physicians recognize this opportunity and have expressed interest in engaging older adults with serious illnesses in a discussion of their end-of-life care. However, there is no consensus regarding the criteria for “palliative care eligibility,” and it is difficult to identify older adults with serious illnesses who may benefit from communication about goals of care. Further, the lack of training in serious illness communication and the chaotic nature of the ED environment discourage physicians from conducting in-depth conversations with these patients. Approaches to identify such patients, as well as feasible methods to intervene in the ED constrain our current clinical practice. We propose to close this gap by developing a practical method to identify older adults with limited life expectancy in the ED and empower them to formulate their goals for end-of-life medical care. Identification: Asking physicians the “surprise question,” worded as, “Would you be surprised if this patient died in the next 12 months?” has been shown to accurately predict 12 month mortality in patients on hemodialysis and patients with cancer in the outpatient setting. Ease of use and prognostic accuracy make the “surprise question” ideal for use in the ED, but its utility in this setting has never been studied. Empowerment: A brief motivational interview ED intervention will be tested as a way to empower such patients to formulate and communicate their goals for medical care. We are already developing such an intervention, with funding from the Emergency Medicine Foundation. Originally designed to empower patients presented to the ED for alcohol abuse, motivational interviewing methods have been demonstrated robustly to improve outcomes by helping patients understand the obstacles to and reasons for their medical care. The brief motivational interview method allows physicians to engage older adults in thinking about the importance of establishing care goals without conducting a time- consuming, sensitive conversation in the hectic ED environment. If shown to be effective, the identification and empowerment methods could be widely disseminated to 5,000 EDs in the U.S. to facilitate care concordant to patient's goals and improve health outcomes towards the end of life.

Project Narrative This project will create a scalable method to identify and empower older adults with serious illness to start formulating their goals for future medical care in the emergency department (ED). We propose to use a robust clinical and administrative database matched with the National Death Index to validate a clinical instrument to identify older adults with limited life expectancy in the ED. Further, we propose to pilot test a brief motivational interview ED intervention to empower such patients to formulate their goals for end-of-life care and determine its feasibility and follow-up on the primary outcome (rate of patients self-report the conversation about their values and preferences for end-of-life care with their outpatient clinician) and other patient-reported outcomes for our future randomized clinical trial.