Emergency department-based, nurse-initiated, serious illness conversation intervention for older adults: a protocol for a randomized controlled trial

Abstract Background: Visits to the emergency department (ED) are inflection points in patients' illness trajectories and are an underutilized setting to engage seriously ill patients in conversations about their goals of care. We developed an intervention (ED GOAL) that primes seriously ill patients to discuss their goals of care with their outpatient clinicians after leaving the ED. The aims of this study are: i) to test the impact of ED GOAL administered by trained nurses on self-reported, advance care planning (ACP) engagement after leaving the ED; and ii) to evaluate whether ED GOAL increases self-reported completion of serious illness conversation and other patient-centered outcomes. Methods: This is a two-armed, parallel-design, single-blinded, randomized controlled trial of 120 seriously ill older adults in two academic and one community EDs in Boston, MA. Participants are English-speaking adults 50 years and older with a serious life-limiting illness with a recent ED visit. Patients with a valid MOLST (medical order for life-sustaining treatment) form or other documented goals of care within the last three months are excluded. We enroll the caregivers of patients with cognitive impairment. Patients are assigned to the intervention or control group using block randomization. A blinded research team member will perform outcome assessments. We will assess i) changes in ACP engagement (surveys, electronic medical record (EMR) documentation of new serious illness conversations, and self-reported completion of serious illness conversations) within six months; and ii) qualitative assessments of the effect of ED GOAL. Discussion: In seriously ill older adults arriving in the ED, this randomized controlled trial will test the effects of ED GOAL on patients’ self-reported ACP engagement, EMR documentation of new serious illness conversations, and improving patient-centered outcomes. Trial registration: Clinicaltrials.gov identifier: NCT05209880