Advance Directives and Goals of Care in the Emergency Department: A Preliminary Analysis of Documentation in Electronic Medical Records

Background: Emergency department (ED) admissions near the end of life often result in care that does not align with patients' documented advance directives and goals of care (DADGOC), yet data on the prevalence and accessibility of this documentation remain limited.This study describes the types and frequency of DADGOC available in the electronic health record (EHR) for patients with palliative care needs admitted through the ED. Methods:We reviewed 2019 EHR data from adults admitted to two New York City EDs who received palliative care consults or comfort care orders.Using a structured review, we identified the presence and type of DADGOC, including healthcare proxy, Medical Orders for Life-Sustaining Treatment (MOLST), do not resuscitate (DNR) orders, living will, advance care planning notes, other clinical notes, or other advance directives.Results: Among 1,108 patients, 559 (50.5%) had multiple documentation types, 430 (38.8%) had one, and 119 (10.7%) had none.Healthcare proxy was most common (n = 512; 52.1%), followed by advance care planning notes (n = 430; 43.5%), DNR (n = 342; 34.6%), other clinical notes (n = 183; 18.5%), MOLST (n = 176; 17.8%), living wills (n = 27; 2.7%), and other directives (n = 2; 0.2%).Among those with only one type, healthcare proxy (n = 131; 30.5%) and advance care planning notes (n = 111; 25.8%) were most common. Conclusion:DADGOC is scattered across the EHR and often difficult to locate.Detailed legal forms were uncommon, highlighting the need for better documentation and centralized access.