Emergency departments (ED) care for all patients, including those living with serious illnesses. 75% of patients over 65 years old visit an ED during the last six months of their life, and 51% of patients visit the ED in the last month of their life [1]. Additionally, 77% of patients seen in the ED in their last month of life are admitted and more than half will die while admitted to the hospital [1]. Up to 80% of cancer patients visit the ED within the last six months of life and two-thirds visit more than once [2]. In 2019, a national study estimated that 2700 individuals per day experience non-sudden deaths without the benefits of hospice [3].

While an increasing body of evidence shows that palliative care and hospice interventions in the ED can benefit both patients and systems, there is little literature on how to identify and/or drive interventions on these patients in the ED [4,5]. Recent studies have shown that discharging patients to hospice from the ED is logistically feasible [6]. The American College of Emergency Physicians Choosing Wisely campaign encourages ED physicians and Advance Practice Providers (APPs) to engage palliative and hospice care services in the ED for patients who would likely benefit as this could prevent unwanted hospital admissions [7]. Avoiding unwanted admissions is desirable for patients and families, as many patients with serious illness do not want to spend their last days in the hospital [8].

There are many barriers to having in-depth goals of care conversations in the ED. Some ED physicians are uncomfortable discussing end-of-life wishes with patients [9,10]. Additionally, there is no established best practice for communication in this specific area [11]. Time constraints, lack of immediate access to hospice and palliative medicine specialists, and ED crowding are also barriers to hospice-centered interventions in ED settings [[12], [13], [14]].

Clinical care pathways (CCP) have been shown to improve adherence to evidence-based guidelines, decrease provider variability, and provide better patient outcomes [15]. CCPs have been successfully utilized across multiple care settings, including end-of-life and palliative care interventions [14,[16], [17], [18], [19]]. We developed clinical and process guidelines for patients with the potential need for hospice services, organized them into a CCP, and sought to evaluate the effect of utilizing the CCP in the ED setting. The primary outcome measure was hospice care referral in the ED. Secondary outcomes included length of stay, social work consultation, and ED disposition.