time-limited trials in the emergency department

Conditions: Emergencies

Summary: a randomized controlled trial of a structured conversation between clinicians and patients/surrogates to facilitate shared decision-making for intensive care use in seriously ill older adults being admitted to the intensive care unit from the emergency department.

a randomized controlled trial of a structured conversation between clinicians and patients/surrogates to facilitate shared decision-making for intensive care use (i.e., time-limited trial, tlt) in seriously ill older adults being admitted to the intensive care unit from the emergency department (ed). the goal is to evaluate the feasibility and acceptability of tlt initiated in the ed for seriously ill older adults who are starting intensive care. the main questions it aims to answer are: * is tlt feasible to be conducted by trained ed clinicians? * do patients or their surrogates find tlt acceptable in understanding and respecting their end-of-life care preferences? participants will be: * attending physicians, resident physicians, or mid-level providers working in the ed who are willing to be randomized to become the study interventionists to conduct tlt conversations. * seriously ill older adults receiving intensive care in the ed. researchers will compare clinicians using tlt with those providing usual care to see if tlt leads to improved patient-centered decision-making and better alignment with patients' end-of-life care preferences.

Eligibility criteria:
physician's eligibility: inclusion criteria: * attending physicians, resident physicians, or mid-level providers working in the ed who are willing to be randomized to become the study interventionists. exclusion criteria: * emergency clinicians unwilling to consent and be randomized to intervention tlt training. patient's eligibility: the subjects will be seriously ill older adults, or their surrogates being cared for by the participating emergency clinicians (both the intervention or control arms). if the emergency clinicians determine that the patient is not able to provide consent due to cognitive impairment, dementia, delirium, or critical illness, the surrogates will participate in the tlt conversations. inclusion criteria: 1. ≥50 years or older with ≥one serious life-limiting illness\* being admitted to the intensive care unit in the ed; or 2. ≥75 years or older being admitted to intensive care unit in the ed; or 3. ed clinicians will not be surprised if the patient died in the current hospital admission or in the near future; and 4. english speaking \*serious illness criteria with high one-year mortality are selected based on best practice recommendations such as 1) stage iii/iv or metastatic cancer; 2) end-stage renal disease on dialysis; 3) chronic heart/lung disease requiring home oxygen supplementation or experiencing shortness of breath with walking; 4) moderate to severe dementia (surrogate required for enrollment); or 5) ≥2 hospitalizations or ed visits in the past six months. exclusion criteria: 1. unable or unwilling to provide informed consent; or 2. non-english speaking; or 3. clinically inappropriate, determined by emergency clinicians, and no surrogate is available

Keywords: time-limited trials; emergency department; palliative care