Table 2.

Major Themes Identified in the Qualitative Interviews

Prespecified domain	Emerged theme	Representative quotes (participant ID no.)
Prior experience with serious illness conversations	Infrequent, mostly occurs in critical care settings	“I don't think in our ED we, very often, initiate those conversations…The only times that it really every comes up is…if the patient is in a very critical condition and is kind of meeting that point where they need comfort measures only. But with more chronic conditions where the patient is otherwise stable, I don't find too often that we are initiating those conversations in the ED…And, most often, those are led by the providers or the clinicians, not so much the nursing.” (11)
	Rapport with patient driving serious illness conversation	“I think it's very important that the rapport drives the consultation and not necessarily the comorbidities or the chronic illness.” (12)
Overall impression of ED GOAL	Positive	“My overall impression is that this is fantastic and that this needs to be pushed further and it needs to start happening more…I think that especially since we see such a … specific patient population where they're [patients are] critically ill…I think that this would be a wonderful added aspect of their care within the ER” (7) “I think having nurses do it might be a little bit more—because we spend a little more time with the patients during their visits than the physicians get a chance to. So, I think it might—being able to expand that into a nursing role might actually be able to make it happen more often.” (10)
	Neutral or negative	“I think it's very well organized. I do think it can turn into like a very long conversation, which I don't know if it's always feasible depending on how busy the ED is. But I like how it's [the ED GOAL intervention is] very structured.” (19) “It's difficult, especially in the emergency department, when someone is having a healthcare crisis, to bring this up… everything is so rushed and maybe a physician won't have the time to spend with the patient to be able to discuss everything like this. However, on the other hand, I see the need for this and I—with people who do have a primary care physician, this is, in my view, a very, very good script to use when approaching this kind of a scenario.” (20)
Refinements to ED GOAL	Add: identify additional actors central to the patient's medical care	“is there anyone who you would want kind of included in this planning in terms of like family or a caretaker included in this planning or would be helpful to reach out to … kind of discuss your overall goal planning” (19)
	Add: asking permission to disclose patients' wishes to other clinicians	“do you mind if I share some of these answers with your ED provider and we can kind of come up with a plan from there to kind of make you feel more comfortable or how to get some of your questions or your goals reached in the outside setting?” (19)
	Remove: coordinating with the patient's primary provider (second to last statement in Part 6 of ED GOAL script)	“we're almost making promises that we can't keep. Like, oh, we'll get you an appointment where your doctor can just talk about your concerns. I think, realistically, is that something that we could provide? Maybe we could put … I will send Dr. so and so an e-mail voicing your concerns and that could be something that you can follow-up with.” (6)
Implementation of ED GOAL by ED nurses: barriers	Lack of time	“It's just finding the time to actually sit down and have this and to actually make it sound genuine, without feeling rushed.” (9)
	Nurse pushback	“We have so many little assessments that we're supposed to ask every patient that comes into the ED. So I think that would be like the greatest resistance” (19)
	Varying comfort levels of ED nurses in having serious illness conversations	“I can imagine, realistically, that there are some nurses who wouldn't feel as comfortable having these conversations. Every nurse has a little bit of a different preference and background. And I, myself, would feel comfortable. But I can imagine that there are some nurses who would not.” (11)
	Difficulty of clear pass off of serious illness conversation findings to outpatient provider	“I guess more along the lines of the documentation piece, just follow-up. You've had this conversation, you've gotten—you've really gotten to a good place with the patient. Now what? Where—what happens now? And I know the follow-up in the script is relaying to their doctor. But, if these patients are being admitted to the hospital, how do we relay this information to the receiving nurses and receiving doctors, and care team, and just kind of, again, get everyone on the same page?” (11)
Implementation of ED GOAL: logistical needs of ED nurses	Need for a clear method of identifying appropriate patients for ED GOAL	“Maybe it's one of the things that's addressed in triage like, does this patient have any advanced care planning? And it's a simple yes or no. And then, if it's a yes, we confirm with the patient what that is. And then, if it's a no, it gets flagged for the primary nurse that's maybe taking care of that patient to have that conversation with them.” (9)
	Need for administrative support	“I mean, we have to have the buy-in of the administration. We have to have the buy-in of the nursing director and the medical director of the ED” (10) “I just think having the support from leadership, I think, is—if we make it a priority, it will be done. And that's been my experience with most of the kind of the assessments and interventions that we do in the ED. It requires the support of leadership. It requires someone to step forward and say, this is a priority, this is why it's a priority. People just need to understand why they're doing these things, and that it's not just checking a box.” (23)
	Need for interdisciplinary effort	“I feel like it would be a team approach. I wouldn't wanna be the sole person initiating the conversation, because I feel like the patient will have a lot of questions that the provider will be better off answering than myself. So, I think it'll be a combined team approach.” (11)
Implementation: ED GOAL training	Content of training	“I think training on the purpose of the tool, kind of when to use the tool, and then some coaching as to—to kind of get people comfortable with the language, if they're not comfortable with having this type of a conversation. How to have this conversation without being—feeling—without it feeling forced, or awkward…” (23)
	Way to evaluate nurses' competency in administering ED GOAL	“So I would go right to the nurse and say what is your comfort level with this? And do you want to have some conversations or would you like the competency related to this? And that would probably be the best way to do it—have it built into our competencies.” (2)
Specially trained nursing model	Benefits of having all ED nurses vs. specially trained nurses equipped to do ED GOAL	“They're actually sort of like your Dr. [Last Name] video there, you're actually taking away that crazy barrier where, oh, wait a minute, I'm getting beeped, oh, wait a minute, I'm getting a call, oh, wait a minute. You know what I mean? So you're actually—like the SANE nurse, she really—she dedicates time to her patients. So it'd be perfect.” (8) “I think all of the nurses should be trained on it, and then to kind of have some nurses that are more like the champions of—the ACP champions that could support the nurses. Because every nurse needs to know how to have these conversations. And then, that way, what happens if maybe that special nurse–specialty nurse isn't there that day? But it would be a nice resource for those nurses that didn't feel as comfortable. But I think everybody should be trained. But I think, at the same time, it's good to have a few of the specially trained nurses, for sure.” (9)
Use of telehealth with ED GOAL	Reasons for	“Before this COVID, I would have thought that that wouldn't be the right way to do it…But in reality, I think that this could—telehealth could have a place in this [for ED GOAL].” (28) “I think it would be a great one because it would cut down on travel time and it would be a little more convenient for the patient and the staff member because— if the patient's able to effectively receive the information through that method, then I think it would probably make things easier. If your nurse who's not directly next to the patient can just call them and have this conversation, it would be much more efficient—I would say that.” (29)
	Reasons against	“But I do think it takes away from the more personal elements of the conversation, just the ability, like I said, to sit at the bedside with the patient and hold their hand and comfort them, and provide them with a cup of water, or a blanket, or something. The telehealth model is really, really beneficial but it kind of takes away that personal affect.” (11) “I'm not sure that all of our patients, particularly some of the elderly, they can't hear it. It's kinda loud and confusing. I think a one to one—one-on-one person would probably be a better venue for this conversation.” (10)