Emergency nurses view lack of privacy, concerns about delayed patient throughput, and perceived difficulty as barriers to having serious illness conversations with patients in the emergency department (ED) setting, a recent study found.1 “Historically, the role of the ED is to diagnose acute issues and to resuscitate patients when they are unwell. But we have a better understanding now, as many diseases become more chronic, that providing care that is concordant with patient values is also an important aspect of what we provide,” says Laura E. Walker, MD, MBA, one of the study authors and a consultant in the Department of Emergency Medicine at Mayo Clinic.
To conduct a high-quality serious illness conversation, providers need adequate time. Providers must learn about the patient’s background and motivations, and the patient’s understanding of their disease. “Barriers to these conversations have been illustrated fairly widely. We wanted to learn more about those barriers, and identify and implement opportunities to overcome them,” says Walker.
Walker and colleagues analyzed survey data from 2,176 ED nurses in 33 EDs who received End-of-Life Nursing Education Consortium training. Most (67.7%) of the nurses reported encountering barriers while engaging in serious illness conversations. “In order to provide the best care for the individual patient, it should be tailored to their values and preferences. Without exploring those, we are substituting our judgment for the patient’s,” explains Walker.
Acutely ill patients may not be in a position to make serious decisions about their care. Time often is a constraint in the ED. “The patient is usually not with us long enough to get the most accurate prognostication of the trajectory of the disease,” says Walker. Unlike other settings, such as the intensive care unit (ICU), the ED is not the ideal location for a formal ethics consult. “When a more in-depth investigation into underlying ethical dilemmas is needed, ED clinicians often err on the side of resuscitation and deferral to an inpatient setting,” notes Walker.
ED providers work to stabilize the patient’s condition while also trying to figure out what the patient’s personal goals and values are. Ideally, that conversation could be started while the care team is getting the patient settled into the ED, establishing what is happening, how to work it up, and how to best provide care. As the patient continues through their course in the ED and is either admitted or discharged, documentation in the electronic health record that reflects the conversation provides continuity to the next team.
“The earlier and more often these conversations can take place with patients and be documented, the easier it will be for the next care team to provide the right care to the patient and understand what they want,” concludes Walker.
- Adeyemi O, Walker L, Bermudez ES, et al. Emergency nurses’ perceived barriers and solutions to engaging patients with life-limiting illnesses in serious illness conversations: A United States multicenter mixed-method analysis. J Emerg Nurs 2023;Nov 15:S0099-1767(23)00249-0. doi: 10.1016/j.jen.2023.09.010. [Online ahead of print].
