As they near the end of life, long term care (LTC) residents often experience unmet needs and unnecessary hospital transfers, a reflection of suboptimal advance care planning (ACP). We applied the knowledge-to-action framework to identify shared barriers and solutions to ultimately improve the process of ACP and improve end-of-life care for LTC residents. We held a 1-day workshop for LTC residents, families, directors/administrators, ethicists, and clinicians from Manitoba, Alberta, and Ontario. The workshop aimed to identify: (1) shared understandings of ACP, (2) barriers to respecting resident wishes, and (3) solutions to better respect resident wishes. Plenary and group sessions were recorded and thematic analysis was performed. We identified four themes: (1) differing provincial frameworks, (2) shared challenges, (3) knowledge products, and 4) ongoing ACP. Theme 2 had four subthemes: (i) lacking clarity on substitute decision maker (SDM) identity, (ii) lacking clarity on the SDM role, (iii) failing to share sufficient information when residents formulate care wishes, and (iv) failing to communicate during a health crisis. These results have informed the development of a standardized ACP intervention currently being evaluated in a randomized trial in three Canadian provinces.

Introduction: The Institut national d'excellence en santé et en services sociaux in Quebec published guidelines suggesting that emergency physicians should establish emergency department (ED) patients’ goals of care when appropriate. The objective of this study was to explore emergency physicians’ opinions about leading goals of care discussion (GCD) in their daily practice. Methods: This study used a qualitative design based on the Normalisation Process Theory (NPT); a middle-range theory used to explain the sustainability of implementing complex healthcare interventions. It was conducted in a single academic ED in Lévis, Québec. We planned to recruit a minimal convenience sample of 10 participants. Between April and May 2018, we conducted semi-structured interviews and transcribed the audio records verbatims. Deductive thematic analysis based on the NPT was conducted using Nvivo 12.0. Two authors codified the content of each interview under the four NPT macro-level constructs: coherence, cognitive participation, collective action and reflexive monitoring. A kappa score was calculated to measure the coding inter-rater reliability. Results: We interviewed 10 ED physicians (50 % women; 60% certified by the College of Family Physicians of Canada (Emergency Medicine)). No new ideas emerged after the 9th interview. Our thematic analysis identified 13 themes. Inter-rater reliability of coding was substantial (kappa = 0.72). The coherence construct contained the following themes: common concept of interpersonal communication, efficiency of care and anxiety generated by the discussion, the identification of an acute deterioration leading to the GCD, coming together of clinician, patient and family, and the importance of knowing patients’ goals of care before medical handover. The cognitive participation construct involved the following themes: lack of training on the new goals of care form and availability of reminders to promote the recommendation. One theme characterized the collective action construct: heterogeneous prioritization for leading GCD. The reflexive monitoring construct contained 4 themes: need to take action before patients consult in the ED, need to develop education programs, need for legislation and the impossibility of systematic GCD for all patients. Conclusion: Goals of care discussion is possible and essential with selected patients in the ED. Nevertheless, policy-making efforts remain necessary to ensure the systematization of the recommendation.

Introduction: Advanced care planning (ACP) and Goals of Care (GOC) discussions are becoming increasingly common in our emergency departments (ED). The national ACP task group has found that the majority of Canadians have not had prior ACP/GOC discussions, nor have they obtained proper documentation of their wishes. The task of having these difficult but important conversations falls frequently to the ED. Despite this, our emergency medicine (EM) residents receive little formal training in ACP discussions. To address this need, we developed and implemented a workshop in ACP/GOC conversations for the University of Alberta EM academic curriculum. Methods: A literature search was performed to identify best practices for ACP discussions in the ED, barriers to ACP in the ED, and tools for identifying ED patients appropriate for ACP. Experts in ACP/palliative care and staff ED physicians were asked to identify previous difficult ACP discussions and highlight aspects of these cases that were challenging in the ED environment. These experiences, best practices and published APC curricula informed the development of a 3-hour case-based workshop that was implemented in the 2016/17 academic year for EM staff and residents. Results: Cases utilized in the workshop emphasized common ACP/GOC situations that occur in the emergency department: Case 1: An 84 year old with C1 GOC whose family did not accept the GOC designation. Case 2: A 72 year old with multiple comorbidities arriving intubated with no GOC documented. Case 3: An 82 year old with decreased LOC whose family asks for an ACP discussion in the ED. Participants were divided into groups (5-6 members). Each small group analyzed and discussed each case before the participants reconvened and discussed their opinions in one large group. ACP experts from palliative care, emergency medical services and EM facilitated the discussions highlighting the best practices from the literature for each case reviewed. Pre and post Likert surveys were distributed to workshop participants to assess changes in confidence in a variety of domains. A Wilcoxon Signed Rank Test showed statistically significant improvement in learner confidence within the following areas (N=21; P<0.05): identifying patients appropriate for GOC discussions, initiating GOC discussions, and identifying barriers to GOC, in the ED. The majority (89%) of participants agreed the workshops should become part of our academic curriculum. Conclusion: An ACP/GOC workshop was successfully implemented and further ACP/GOC sessions are planned for the upcoming academic year. Looking ahead, we will look at using other teaching modalities such as simulation to further enhance the delivery of the curriculum. We will also attempt to capture defined physician behaviors (e.g. documenting GOC in the ED chart, sending letters to family physicians documenting GOC discussions) to gauge uptake of the workshop principles into clinical practice.