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. 2025 Aug 2;17(8):e89248.
doi: 10.7759/cureus.89248. eCollection 2025 Aug.

Absence of Medical Record Documentation of Advance Care Planning Status in At-Risk Emergency Department Patients

Jessica K Eygnor  1 , Jennifer E Allen  2 , William G Carmichael  1 , Katie M Best  2 , David B Burmeister  1 , Katelyn L McLain  1 , Zhe Chen  1 , Justin M Stauffer  1 , Courtney M Moore  1 , Anthony Schinelli  1 , David M Richardson  1 , Matthew M McCambridge  3 , Marna R Greenberg  1 , Timothy J Friel  4
Affiliations

Absence of Medical Record Documentation of Advance Care Planning Status in At-Risk Emergency Department Patients

Jessica K Eygnor et al. Cureus. .

Abstract

Background The majority of those aged 65 and older will visit the emergency department (ED) in the last six months of life. Knowing a patient's goals of care is important, and existing medical records do not always represent them well. We set out to determine the baseline availability of advance directives and goals of treatment in those ED patients at increased risk for mortality. Methods This prospective cohort study included a sample of adult ED patients who had a mortality predictor by an End-of-Life (EOL) Deterioration Index-guided electronic best practice advisory (BPA) or admission to any of the network's intensive care units (ICU). Electronic medical record (EMR) abstraction was used to evaluate for documentation of healthcare proxy, healthcare power of attorney (POA), living will, advance care plans, or physician orders for life-sustaining treatment (POLST). Results A total of 9,321 patient encounters, representing 7,204 unique patients, were included in the analyzed sample. Most patients' charts lacked advance care planning documentation such as healthcare proxy (98.7%, N=9200), healthcare POA (93.0%, N=8665), living will (94.6%, N=8816), advance care planning status (66.8%, N=6226), and POLST (95.8%, N=8928). Overall, urban sites had a larger percentage of encounters in which a high-risk patient might benefit from advance care planning discussions than rural sites. Females had a higher percentage of documentation across all variables of goals of care, with significant differences in healthcare POA (p < 0.001), advance directives (p < 0.001), and POLST (p = 0.008). Conclusions The majority of patients with a higher risk for mortality, as indicated by an EOL Deterioration Index-guided BPA or hospital ICU admission, do not have documentation in the EMR across all variables of goals of care.

Keywords: advance care planning; electronic medical record (emr); emergency department; goals of care; palliative care.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Lehigh Valley Health Network Institutional Review Board issued approval (STUDY00001245). Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

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