Early Goals of Care Conversations Ensure Ethical Care in the ED

By Stacey Kusterbeck

When a critically ill patient comes to the emergency department (ED), there are multiple reasons why goals of care discussions usually do not happen until after admission. Payal Sud, MD, FACEP, experienced this problem firsthand with a family member who was diagnosed with lung cancer. The family member had multiple ED visits, and multiple doctors were involved in her care. During one visit, an oncologist reviewed lab and radiology results with a positive outlook.

Sud had a different perspective, knowing that her relative previously had been very active but now needed assistance even to go to the bathroom or be bathed. “Everyone was trying to do the best thing possible. But it really made me ask: What are we doing? We are treating the numbers — but are we really talking about what matters most to the patient?” says Sud, an associate chair of emergency medicine at North Shore University Hospital and chief of geriatric emergency medicine at Northwell Health. Sud also is assistant professor of emergency medicine at the Zucker School of Medicine at Hofstra/Northwell.

Around this same time, Northwell Health was implementing an initiative to improve care of older adults in the ED. As the physician leader in the ED, Sud saw the need to focus on what matters most to patients when they present to the ED. “In trauma care, we call it the golden hour of treatment. But what if we view the golden hour as being able to connect with patients the moment they enter the ED about what really matters to them?” says Sud. In some cases, a critically ill older patient presents to the ED and providers focus on preparing for the patient to be admitted, only to find out hours later that the patient was never intending to stay in the hospital because of family obligations or other reasons. If a discussion took place early in the ED visit, providers could come up with a different plan, such as home care or hospice care.

As part of the initiative to improve the care of older ED patients, the ED worked closely with palliative care providers, hospital leadership, and the finance team. “All ED providers are trained to have in-depth goals of care conversations. But we all know, realistically it is not always possible to provide an hour-long conversation with the family involved due to the pace of care in the ED,” says Sud. Sometimes ED physicians would start the discussion, and the palliative care team ideally would take over before the patient was hospitalized. The problem was that the palliative care team was stretched too thin to have all those discussions in the ED. “They just didn’t have the bandwidth to do this. Their response time, on average, was about six days after the patient was admitted. Obviously, in the ED, we are working in a time frame of minutes to hours,” says Sud.

It was clear that a palliative care clinician dedicated to the ED was needed. To justify this from a financial standpoint, Sud and colleagues conducted a study comparing outcomes and cost savings when goals of care conversations happened in the ED vs. inpatient settings.¹ The researchers analyzed records of patients 65 years of age or older who received a goals of care conversation from 2021-2023. Of 7,326 patients, 18.1% received a goals of care conversation in the ED and 8.1% received a palliative consultation in the ED.

ED goals of care conversations were linked to a decreased length of stay, fewer excess days in acute care, and increased contribution margin. ED-initiated palliative consults were linked to a reduced length of stay, fewer intensive care unit (ICU) days, fewer excess days in acute care, and an increased likelihood of being discharged from hospice.

“We were able to show that this approach allows us to deliver truly patient-centered care while simultaneously optimizing resource utilization and achieving cost savings — proving that compassionate care and financial stewardship are not mutually exclusive,” says Sud. The researchers used the study findings to justify investment in a dedicated palliative care physician in the ED. Many older ED patients who otherwise would have been hospitalized are instead discharged to hospice, either outpatient or inpatient, as a result of the early palliative care involvement. “Having this in place reduces so much drawn-out agony for many patients and family,” says Sud. Months later, the ED also obtained funding for a hospice nurse in the ED.

Although the researchers did not explicitly study ethical conflicts as a measured outcome, by starting goals of care conversations and palliative consults earlier in the ED, providers increase the likelihood of care aligning with the patient’s wishes. “This will inherently reduce the potential for ethical conflicts that can arise from disagreements over treatment choices,” says Sud.

Early goals of care discussions decreased unwanted intensive care interventions. Ethical conflicts often stem from situations where aggressive, life-sustaining treatments are pursued against a patient’s or family’s wishes, or when there is a lack of clarity about what matters most to the patient. “By clarifying these preferences upfront at the point of presentation to the ED, the need for interventions that might be ethically contentious or distressing for the patient, family, or care team is reduced,” says Sud.

ED-initiated palliative care consults were associated with increased hospice discharge odds. Hospice care focuses on comfort and quality of life rather than life-prolonging treatments. “Ethical conflicts often arise in the gap between aggressive treatment and comfort care. Moving towards hospice philosophy of care earlier, when it aligns with patient goals, reduces the period of uncertainty and potential conflict over what kind of care is appropriate,” Sud says.

ED clinicians may have questions about what point they can determine medical futility. “We’ve had cases where patients presented to the ED with suicidal overdoses and had a DNR (do not resuscitate) [order] in place,” says Sud. ED clinicians consulted the ED-embedded palliative care physician to assist with discussions and decision-making.

“The palliative care doctor rounds in the ED to make herself visible and available,” says Sud. Additionally, a medical ethicist attended an ED faculty meeting along with the palliative care physician to discuss a common ethical dilemma: What should ED providers do if there is no advance care plan and they feel that hospitalization would be futile?

ED providers are more aware of how dramatically the decisions made in the ED can affect the patient’s care. Previously, ED providers often knew that the hospital was not the best place for the patient but had limited resources to arrange discussions and hospice care, so the patients ended up being admitted. “But everything is interconnected,” says Sud.

One patient in her 90s came back every three weeks for a blood transfusion. The patient was well-appearing, but the daughter was exhausted and stressed. Now that the dedicated ED palliative care physician is in place, providers were able to offer the family a better plan. The hospice nurse set up home services to allow the patient to get blood transfusions at home, so the daughter did not have to miss work to bring her in. “Additionally, due to this initiative, we were able to expand our ED-based observation unit with additional nursing resources to accommodate a patient such as this one, to monitor and receive the blood transfusions while home transfusions were set up. Previously, due to the time crunch and lack of resources to focus on these transitions of care in the ED, we would have had to admit this patient,” says Sud.

Cases like this demonstrate that early goals of care discussion and palliative care consults have great benefits for patients and families — and also for ED providers themselves. ED provider notes were modified to add a section for the goals of care discussion. “Anytime we start new initiatives, most of the time it comes with extra work. But with this came a promise: That we will also make your life easier by having this resource available,” says Sud.

Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.

Reference

1. Johnson J, Li T, Mandile M, et al. Benefits of emergency department-initiated goals of care conversations and palliative care consultations among older adults with chronic or serious life-limiting illnesses. J Am Coll Emerg Physicians Open. 2025;6(4):100165.