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Social Worker–led Serious Illness Conversations Feasible in the ED

Key findings

  • This prospective pilot trial was the first to assess the feasibility and acceptability of having social workers conduct serious illness conversations with older adults presenting to an emergency department (ED) who had potential palliative care needs
  • 117 patients who were ≥75 years old and had been triaged to the acute or urgent areas of the ED were randomly assigned to a serious illness conversation with a social worker or usual care
  • It was possible to enroll 55% of patients who were approached, and 66% of patients assigned to the intervention were able to receive it without alteration of the social workers' current responsibilities
  • Most patients found the intervention acceptable: 77% appreciated having the social worker ask them about their goals of care, 72% appreciated being asked about their fears and worries, and 81% liked the way the conversation was set up
  • The novel intervention warrants assessment on a larger scale

When an acutely ill patient presents to the emergency department (ED), there's a clear need to ensure the care options align with the patient's wishes. Still, limited progress has been made toward improving access to palliative care services within EDs.

Social workers are uniquely positioned to explore patients' goals and values because of their holistic approach and their skill at simultaneously addressing patients' individual, family, and sociocultural needs.

In the first study of its type, researchers at Massachusetts General Hospital found a social work–directed palliative care intervention in the ED was feasible and acceptable to both patients and social workers. Emily L. Aaronson, MD, MPH, assistant chief quality officer in the Lawrence Center for Quality and Safety at Mass General, Jeffrey L. Greenwald, MD, a Core Educator Faculty hospitalist in the Department of Medicine and associate director of the Continuum Project for implementing serious illness conversations, and colleagues published their findings in the Journal of Palliative Medicine.


Three ED social workers volunteered to participate in the study in addition to their usual duties and helped design the intervention. Research assistants screened the ED track board seven hours a day, Monday to Friday, for patients who were ≥75 years old, and had been triaged to the acute or urgent areas of the ED.

For eligible patients, research assistants approached the physician and asked the surprise question (''Would you be surprised if this patient died in the next 12 months?''). Patients whose physician answered "No" were approached for consent and enrolled, up to four patients per day. They were randomized 1:1 to have a serious illness conversation facilitated by one of the social workers or to enter a control group.

The social worker documented the content of each conversation in the medical record and communicated their impressions to ED clinicians verbally. Social workers had received structured training on a script for the conversations, which could be personalized. They met with colleagues regularly during the study period to troubleshoot logistics and interaction concerns.


The predetermined indicators of feasibility were:

  • Accrual of 10 patients/month: 211 patients were approached for participation during the study period (December 7, 2020 – March 5, 2021, and May 3 – May 20, 2021), of whom 117 (55%) were randomized at an average of 31 patients/month
  • Lost to follow-up <15%: The actual rate was 12%
  • Intervention completed in ≥60% of patients: Of 65 patients randomized to the intervention group, social workers were able to complete a serious illness conversation with 43 (66%)

The most frequent reason for inability to conduct a serious illness conversation was social worker responsibilities in other areas of the ED (45%).

Acceptability to Patients

38 of the 43 patients completed the Quality of Serious Illness Conversation questionnaire the day after talking with the social worker:

  • 77% appreciated being asked about their goals of care
  • 72% appreciated being asked about their fears and worries
  • 81% liked the way the conversation was set up

On another questionnaire, 44% of the patients said the conversation would influence how they prepared for the future, and 48% said discussing their illness increased their understanding of their prognosis.

Acceptability to Social Workers

The three social workers debriefed their experience in a focus group. Positive themes that emerged were:

  • The work was gratifying, meaningful, and thought-provoking
  • The scope of work aligned well with their training
  • Patients were receptive to the conversations

Challenges included pushback from ED providers, perceived lack of respect for the information social workers conveyed, social workers' lack of knowledge of code status, the barriers inherent to the ED environment, and competing priorities.

The social workers indicated opportunities for improvement:

  • Scripted language to build on conversations started by other members of each patient's care team
  • A system to ensure the content of the conversations are seen and continued by the inpatient team or outpatient primary care physician
  • A way to involve families in the discussions

More Research Warranted

The study demonstrates it is possible to conduct a randomized controlled trial of this novel intervention in the ED. Social workers could prove invaluable at expanding the capacity of EDs across the country to understand the priorities of patients facing serious illness and allow their care to be better aligned with their wishes.

of older, acutely ill patients in an emergency department appreciated having a social worker discuss their goals of care with them

of older, acutely ill patients in an emergency department liked the way a social worker set up a serious illness conversation with them

Learn about the Division of Palliative Care and Geriatric Medicine

Refer a patient to the Division of Palliative Care and Geriatric Medicine


Early in the COVID-19 pandemic, a team of volunteer clinicians at Massachusetts General Hospital gave rapid, confidential assistance to peers working to clarify values and goals of care with patients.


Emily L. Aaronson, MD, MPH, served as the first author of a "roadmap" for researchers who seek to establish the value proposition of integrating palliative care into emergency departments and develop sustainable, reproducible, measurable, and unbiased interventions.