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Care discussions need to take place sooner, research shows

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PROVIDING greater opportunity for patients to have discussions around long-term health management before an acute event occurs could support better goals of care conversations in hospital, new research says.

Researchers from the Bolton Clarke Research Institute, Monash University, Cabrini Melbourne Emergency Department and the University of Melbourne explored the perspectives of Emergency Department (ED) doctors on ED-led goals of care discussions at a Melbourne private hospital emergency department.

Eighteen doctors who completed a Goals-of-Care form with a patient contributed to the study, which was published in Psychology Health & Medicine.

Doctors reported these conversations occurred about once per shift and were increasing in frequency.

The research – the first of its kind focused on characterising goals of care conversations in the emergency setting – found there was no common understanding of terminology and goals of care were often confused with treatment limitations and Advance Care Plans.

Many Emergency Department doctors believed patients were not being accurately prepared for end of life by their long-term physicians.

Data supported this, with only around 30 per cent of the patients involved having an Advance Care Plan, despite high health literacy and access to care.

The ED doctors interviewed were often more focused on available medical treatments and where there were no curative options they were more likely to consider patient values and longer-term goals.

Doctors appeared to have challenges acknowledging patient and family perspectives when completing sections of the form dealing with quality of life as defined by the patient, and some assumed this was a doctor-assessed measure.

“This is something that I probably (had) not really talked about with the patient much in the past…in the last year or so it’s coming more into the conversation,” said one ED doctor.

“I might have made an assumption about what their quality of life was like, I think that assumption turned out to be wrong.”

“Maybe we’re guilty…of having preconceived goals-of-care in our own mind from a medical perspective, rather than actually sitting down with the patient’s family and making sure they have similar sense,” another participant said.

The study findings were consistent with previous work around the poor understanding of palliative care concepts in Australian Emergency Departments and concerns around assessment of quality of life, an important goal of care.

“Improving end-of-life care is a high priority for Emergency Medicine research and the need for these discussions is likely to increase as population demographics change and new medical technologies become available,” the researchers found.

“In an increasingly fragmented healthcare system co-ordination of care is vital, and all practitioners regardless of speciality must take responsibility for serious illness conversations.”

Michele Levinson, Katherine J Walker, Jennifer Hanning, William Dunlop, Edward Cheong & Amber Mills (2019): Medical perspectives regarding goals-of-care consultations in Emergency Departments, Psychology, Health & Medicine, DOI:10.1080/13548506.2019.1595683