ED GOAL is a 6-minute, motivational interviewing, advance care planning intervention.

In this study, the investigators will pilot test (Part I) ED GOAL by training research nurses to demonstrate its intervention fidelity and acceptability on older adults with serious illness in the emergency department (ED). Upon demonstrating the intervention fidelity of this intervention in Part I, the investigators will collect patient-centered outcomes (Part II) of 100 older adults with serious illness after leaving the ED. Further in Part III, the investigators will conduct a survey to the participants' outpatient clinicians to find out how to optimize the care coordination from the ED to the outpatient office to facilitate advance care planning conversations.

Part 1.

Inclusion Criteria:

• ≥50 years of age AND ≥1 Serious illness* OR ED clinician would not be surprised if patient died in the next 12 months
• English-speaking
• Capacity to consent

Exclusion Criteria:

• Acute physical or emotional distress
• Determined by EM physician not to be appropriate
• Clearly documented goals for medical care** (Unless the treating clinician recommends that the patient needs the intervention)
• Delirium (assessed using 3D-CAM)
• Mild cognitive impairment or dementia (assessed using MiniCog or SBT)
• Already enrolled in this study
• Unable/unwilling to schedule the follow-up outcomes assessment on the calendar.

Part 2.

Inclusion Criteria:

• ≥50 years of age AND ≥1 Serious illness* OR ED clinician would not be surprised if patient died in the next 12 months
• English-speaking
• Patient with mild cognitive impairment or mild dementia with caregiver has a capacity to consent
• Caregivers of patients with moderate/severe dementia has a capacity to consent

Exclusion Criteria:

• Acute physical or emotional distress
• Determined by EM physician not to be appropriate
• Clearly documented goals for medical care** (Unless the treating clinician recommends that the patient needs the intervention)
• Delirium (assessed using 3D-CAM)
• Already enrolled in this study
• Unable/unwilling to schedule the follow-up outcomes assessment on the calendar.

(*NYHA Stage III/IV congestive heart failure, chronic obstructive lung disease on home oxygen, chronic kidney disease on dialysis, or metastatic solid tumor cancer. In addition, patients with NYHA Stage I/II congestive heart failure, chronic obstructive lung disease not on home oxygen, chronic kidney disease not on dialysis, solid tumor cancer without metastasis will be included if recent hospitalization in the last 12 months exists.) (**MOLST, medical order for life-sustaining treatment.)