Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework

Melissa Sheber; Mackenzie McKnight; Daniel Liebzeit; Aaron Seaman; Erica K Husser; Harleah Buck; Heather S Reisinger; Sangil Lee

doi:10.1002/emp2.13012

Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework

J Am Coll Emerg Physicians Open. 2023 Jul 28;4(4):e13012. doi: 10.1002/emp2.13012. eCollection 2023 Aug.

Authors

Melissa Sheber¹, Mackenzie McKnight¹, Daniel Liebzeit², Aaron Seaman³, Erica K Husser⁴, Harleah Buck², Heather S Reisinger³, Sangil Lee⁵

Affiliations

¹ Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City Iowa USA.
² University of Iowa College of Nursing Iowa City Iowa USA.
³ Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City Iowa USA.
⁴ Ross and Carol Nese College of Nursing Pennsylvania State University, University Park Pennsylvania USA.
⁵ Department of Emergency Medicine University of Iowa Carver College of Medicine Department of Epidemiology University of Iowa College of Public Health Iowa City Iowa USA.

Abstract

Background: We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting.

Methods: A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework.

Results: A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry.

Conclusions: Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.