Providing high quality emergency care to individuals with serious, life-limiting illness starts with an understanding of their treatment goals and care preferences above all else. Speaking as a critical care physician, this is absolutely essential information to have at the time of an emergency. It helps me to formulate a plan to provide the best possible care for an individual in the context of their wishes. It also helps to frame care recommendations when speaking to families, and to support them through the difficult task of speaking for a loved one who cannot be heard. So I was very interested to see two recent publications in the Journal of Palliative Medicine relating to accessibility of advance care planning (ACP) documents in the emergency department (ED).
The first study from Angelo Volandes’ group looked at 104 elderly individuals presenting to the ED at an academic medical center. Participants were asked about whether they had completed any ACP documents, and the electronic chart was then reviewed for the presence of these documents or current code status in the chart. Fifty-nine (59) percent of participants reported completing some form of ACP document. The majority were living wills (52%) and healthcare power of attorney (54%), with fewer having DNR (38%) or MOLST (6%) forms.
Did the ED provider have access to these documents? The short answer is no. Only 8% of participants had a current code status in the chart, and only 13% had any form of advance care documentation locatable in the EHR. Of the 13 people who said they had given a copy of ACP documents to the hospital previously, only 31% could be found in the EHR, and of the 69 participants whose primary care provider was affiliated with the institution only 19% had current code status or ACP documentation available in the EHR.