The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review

Care home residents who die in hospital: exploring factors, processes and experiences

BACKGROUND

Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital.

METHODS

This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives.

RESULTS

During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this.

CONCLUSIONS

Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.

Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial

BACKGROUND

In Germany, advance care planning (ACP) was first introduced by law in 2015. However, ACP is still uncommon in Germany and only few people have advance directive forms. This study aims to evaluate an ACP program in care dependent community-dwelling persons, compared to optimised usual care.

METHODS

A cluster-randomised controlled trial of 12 months duration will be conducted in 3 German study sites comparing the pretested ACP-counselling offered by trained nurses with a control group receiving optimised usual care. Using external concealed randomisation, 16 home care services each will be included in the intervention and the control group (30 participants per cluster; n = 960). Eligibility criteria for patients are: ≥60 years, somehow care dependent, adequate German language skills, assumed life-expectancy of ≥4 weeks, and cognitive ability for participation. ACP will be delivered by trained nurse facilitators of the respective home care services and communication will include proxy decision-makers. The primary endpoint will be patient activation, assessed by the Patient Activation Measure (PAM-13). Secondary endpoints include ACP-engagement, proportion of prepared advance directives, number and duration of hospitalisations, quality of life as well as depression and anxiety. Further, comprehensive economic and process evaluations will be conducted.

DISCUSSION

STADPLAN is the first study in Germany that assesses an adapted ACP intervention with trained nurses in home care services and the first international study focusing on cost effectiveness of ACP in community-dwelling older persons. The results will help to improve the understanding and communicating of patients' preferences regarding medical treatment and care and thereby contribute to patients' autonomy.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00016886 (Date of registration: 04.06.2019).

Ten-year trends in end-of-life hospitalizations of nursing home residents in Germany, 2006-2015

OBJECTIVES

We investigated trends in end-of-life hospitalizations among nursing home residents (NHR) over 10 years and looked at differences between age groups and sexes as well as the length of terminal hospital stays.

STUDY DESIGN

Retrospective cohort study based on health insurance claims data of the AOK Bremen/Bremerhaven. All NHR aged 65 years or more who died between 2006 and 2015 were included.

MAIN OUTCOME MEASURES

We assessed the proportions of decedents who were in hospital on the day of death and during the last 3, 7, 14 and 30 days of life, stratified by two-year periods. Multiple logistic regressions were conducted to study changes over time, adjusting for covariates.

RESULTS

A total of 10,781 decedents were included (mean age 86.1 years, 72.1 % females). Overall, 29.2 % died in hospital, with a slight decrease from 30.3 % in 2006-2007 to 28.3 % in 2014-2015 (OR 0.86; 95 % CI 0.75-0.98). Of the 3150 terminal hospitalizations, 35.5 % lasted up to 3 days and the mean length of stay decreased from 9.0 (2006-2007) to 7.5 days (2014-2015). When looking at the last 7, 14 and 30 days of life, no changes over time were found. Male sex and younger age were associated with a higher chance of end-of-life hospitalization in almost all analyses.

CONCLUSIONS

End-of-life hospitalizations of NHR are common in Germany. There has been a small decrease during recent years in the proportion of in-hospital deaths, but not of hospitalizations during the last 7, 14 and 30 days of life. This might be explained by shorter durations of hospital stays.

Piloting Me and My Wishes-Videos of Nursing Home Residents' Preferences

CONTEXT

A key challenge in nursing homes (NHs) is how to attain and clarify resident preferences for care and then communicate these preferences to family members and staff.

OBJECTIVES

We evaluated the feasibility and acceptability of Me & My Wishes-person-centered videos of residents discussing their preferences for daily and end-of-life (EOL) care.

METHODS

For this descriptive study, Me & My Wishes videos were created with residents in three NHs in the Pacific Northwest. Feasibility was evaluated by tracking resident enrollment, completing and sharing their video, and conducting debriefing interviews to ascertain residents' impressions of the recording process and personalized conversation. After viewing the video, staff and family assessed communication quality via survey-the extent to which they perceived messages from the video (e.g., preferences for EOL) to be timely, accurate, adequate, complete, and credible and items on resident preferences for daily and EOL care.

RESULTS

Twenty of 33 residents approached created videos; 18 of these residents shared their videos with family or staff. Residents reported that they liked the opportunity to express their wishes. On a scale of 1-7 (lower is better), mean ratings were 2.0 (family) and 1.3 (staff) for communicating preferences for daily care; 1.9 (family) and 1.2 (staff) for communicating preferences for EOL. Both family and staff reported increased knowledge about resident preferences for daily and EOL care.

CONCLUSION

This research supports the feasibility and acceptability of a videotaping approach (Me & My Wishes) for viewing, listening, and discussing residents' preferences for daily and EOL care.

Advance care planning for adults with heart failure

BACKGROUND

People with heart failure report various symptoms and show a trajectory of periodic exacerbations and recoveries, where each exacerbation event may lead to death. Current clinical practice guidelines indicate the importance of discussing future care strategies with people with heart failure. Advance care planning (ACP) is the process of discussing an individual's future care plan according to their values and preferences, and involves the person with heart failure, their family members or surrogate decision-makers, and healthcare providers. Although it is shown that ACP may improve discussion about end-of-life care and documentation of an individual's preferences, the effects of ACP for people with heart failure are uncertain.

OBJECTIVES

To assess the effects of advance care planning (ACP) in people with heart failure compared to usual care strategies that do not have any components promoting ACP.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Social Work Abstracts, and two clinical trials registers in October 2019. We checked the reference lists of included studies. There were no restrictions on language or publication status.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ACP with usual care in people with heart failure. Trials could have parallel group, cluster-randomised, or cross-over designs. We included interventions that implemented ACP, such as discussing and considering values, wishes, life goals, and preferences for future medical care. The study participants comprised adults (18 years of age or older) with heart failure.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted outcome data from the included studies, and assessed their risk of bias. We contacted trial authors when we needed to obtain missing information.

MAIN RESULTS

We included nine RCTs (1242 participants and 426 surrogate decision-makers) in this review. The meta-analysis included seven studies (876 participants). Participants' mean ages ranged from 62 to 82 years, and 53% to 100% of the studies' participants were men. All included studies took place in the US or the UK. Only one study reported concordance between participants' preferences and end-of-life care, and it enrolled people with heart failure or renal disease. Owing to one study with small sample size, the effects of ACP on concordance between participants' preferences and end-of-life care were uncertain (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.91 to 1.55; participants = 110; studies = 1; very low-quality evidence). It corresponded to an assumed risk of 625 per 1000 participants receiving usual care and a corresponding risk of 744 per 1000 (95% CI 569 to 969) for ACP. There was no evidence of a difference in quality of life between groups (standardised mean difference (SMD) 0.06, 95% CI -0.26 to 0.38; participants = 156; studies = 3; low-quality evidence). However, one study, which was not included in the meta-analysis, showed that the quality of life score improved by 14.86 points in the ACP group compared with 11.80 points in the usual care group. Completion of documentation by medical staff regarding discussions with participants about ACP processes may have increased (RR 1.68. 95% CI 1.23 to 2.29; participants = 92; studies = 2; low-quality evidence). This corresponded to an assumed risk of 489 per 1000 participants with usual care and a corresponding risk of 822 per 1000 (95% CI 602 to 1000) for ACP. One study, which was not included in the meta-analysis, also showed that ACP helped to improve documentation of the ACP process (hazard ratio (HR) 2.87, 95% CI 1.09 to 7.59; participants = 232). Three studies reported that implementation of ACP led to an improvement of participants' depression (SMD -0.58, 95% CI -0.82 to -0.34; participants = 278; studies = 3; low-quality evidence). We were uncertain about the effects of ACP on the quality of communication when compared to the usual care group (MD -0.40, 95% CI -1.61 to 0.81; participants = 9; studies = 1; very low-quality evidence). We also noted an increase in all-cause mortality in the ACP group (RR 1.32, 95% CI 1.04 to 1.67; participants = 795; studies = 5). The studies did not report participants' satisfaction with care/treatment and caregivers' satisfaction with care/treatment.

AUTHORS' CONCLUSIONS

ACP may help to increase documentation by medical staff regarding discussions with participants about ACP processes, and may improve an individual's depression. However, the quality of the evidence about these outcomes was low. The quality of the evidence for each outcome was low to very low due to the small number of studies and participants included in this review. Additionally, the follow-up periods and types of ACP intervention were varied. Therefore, further studies are needed to explore the effects of ACP that consider these differences carefully.

Implementing the theory-based advance care planning ACP+ programme for nursing homes: study protocol for a cluster randomised controlled trial and process evaluation

BACKGROUND

Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change.

METHODS

We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design.

DISCUSSION

There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov (no. NCT03521206). Registration date: May 10, 2018. Inclusion of nursing homes started March, 2018. Hence, the trial was retrospectively registered but before end of data collection and analyses.

A Retrospective Study Reviewing Interprofessional Advance Care Planning Group Discussions in Pulmonary Rehabilitation: A Proof-of-Concept and Feasibility Study

Background:

Advance care planning (ACP) is a process of reflection and discussion wherein a patient, in consultation with a health-care provider, family, and/or loved ones, clarifies values and treatment preferences and establishes goals, including a plan for end-of-life (EOL) care. Advance care planning encompasses appreciating and understanding illness and treatment options, elucidating patient values and beliefs, and identifying a substitute decision maker (SDM) or designating a power of attorney (POA) for personal care. These discussions have proven to be effective in improving patient–family satisfaction, reducing anxiety regarding EOL care in patients and family members, and improving patient-centered care by empowering patients to direct their care at EOL. However, ACP conversations are often difficult to have due to the sensitive nature of such discussions.

Objective:

The aim of this study was to determine whether group facilitation for teaching and discussing ACP enhances participants’ understanding of ACP and allows them to feel comfortable and supported when discussing these sensitive issues.

Methods:

Patients who were registered in North York General Hospital’s (NYGH) pulmonary rehabilitation program from June 2016 until August 2017 were given the opportunity to attend two 1-hour sessions related to ACP. The first session was dedicated to educating patients on ACP, explaining the hierarchy of the SDM and the role of the POA for personal care. The second session, provided a short time later, was devoted to discussions of values, wishes, fears, and trade-offs for future medical and EOL care. These discussions led by the supportive care nurse practitioner and a physician who are members of the NYGH Freeman Palliative Care Team were held in a group-facilitated format. Anonymous feedback forms, including both qualitative and quantitative feedback, were completed by the participants and analyzed.

Participants:

Analysis of a sample of 30 participants who attended 1 or 2 of the ACP sessions revealed that 21 identified as female and 9 identified as male. The average age of the participants was 76 years.

Findings:

Participants felt the content was relevant to their needs and were comfortable asking questions with all feedback averages ranging from good to very good. Participants appreciated the opportunity to share their thoughts in an open and interactive format.

Conclusion:

Discussing issues relevant to ACP, including providing information about ACP, sharing fears, wishes, and tradeoffs, were well-received in a group-support environment. Future studies should assess the impact of ACP group discussion on the individual, such as identifying a POA, having discussions regarding wishes and values with the SDM/POA, and examining the clinical impact of such sessions.

Advance care planning in Norwegian nursing homes - limited awareness of the residents' preferences and values? A qualitative study

BACKGROUND

52% of all deaths in Norway occur in nursing homes. Still advance care planning (ACP) is scarce and heterogeneous. To improve the implementation and practice of ACP in nursing homes, knowledge about health care professionals' views on ACP is vital. The objective of this study is to explore nurses and physicians' aims and experiences with carrying out ACP in nursing homes.

METHODS

Semi-structured group interviews were conducted with 20 health care professionals, recruited from nursing homes where ACP was performed regularly. Qualitative content analysis was used to analyse the data.

RESULTS

The primary aim of the nursing home professionals when doing ACP in nursing homes were to build alliances with next of kin to avoid misunderstandings and future conflicts. Two main experiences with ACP were described: i) due to the sensitivity of ACP issues, it was important to balance directness with being sensitive, and ii) when the physicians raised questions concerning future medical treatment, the answers from residents as well as next of kin were often hesitant and unclear.

CONCLUSION

Our study add insights into how ACP is practiced in nursing homes and the professionals' agenda. A focus on medical issues and achieving consensus with next of kin may result in lack of involvement of the residents and limited awareness of the residents' needs. Interdisciplinary approaches, ACP-training and tailored guidelines may improve the implementation and practice of ACP.

Improved patient participation through advance care planning in nursing homes-A cluster randomized clinical trial

OBJECTIVE

To improve patient participation in advance care planning in nursing homes where most patients have some degree of cognitive impairment.

METHODS

This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support using a whole-ward approach where regular staff perform advance care planning and invite all patients and next of kin to participate.

RESULTS

In intervention group wards the patients participated more often in end-of-life treatment conversations (p < 0.001). Moreover, the patient's preferences, hopes AND worries (p = 0,006) were more often documented, and concordance between provided TREATMENT and patient preferences (p = 0,037) and next of kin participation in advance care planning with the patient (p = 0,056) increased.

CONCLUSION

Improved patient participation - also when cognitively impaired - is achievable through advance care planning in nursing homes using a whole-ward approach.

PRACTICE IMPLICATIONS

Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be used to implement advance care planning.

TRIAL REGISTRATION

ISRCTN registry (ID ISRCTN69571462) - retrospectively registered.

Improved Quality of Death and Dying in Care Homes: A Palliative Care Stepped Wedge Randomized Control Trial in Australia

OBJECTIVES

Mortality in care homes is high, but care of dying residents is often suboptimal, and many services do not have easy access to specialist palliative care. This study examined the impact of providing specialist palliative care on residents' quality of death and dying.

DESIGN

Using a stepped wedge randomized control trial, care homes were randomly assigned to crossover from control to intervention using a random number generator. Analysis used a generalized linear and latent mixed model. The trial was registered with ANZCTR: ACTRN12617000080325.

SETTING

Twelve Australian care homes in Canberra, Australia.

PARTICIPANTS

A total of 1700 non-respite residents were reviewed from the 12 participating care homes. Of these residents, 537 died and 471 had complete data for analysis. The trial ran between February 2017 and June 2018.

INTERVENTION

Palliative Care Needs Rounds (hereafter Needs Rounds) are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning.

MEASUREMENTS

This article reports secondary outcomes of staff perceptions of residents' quality of death and dying, care home staff confidence, and completion of advance care planning documentation. We assessed (1) quality of death and dying, and (2) staff capability of adopting a palliative approach, completion of advance care plans, and medical power of attorney.

RESULTS

Needs Rounds are associated with staff perceptions that residents had a better quality of death and dying (P < .01; 95% confidence interval [CI] = 1.83-12.21), particularly in the 10 facilities that complied with the intervention protocol (P < .01; 95% CI = 6.37-13.32). Staff self-reported perceptions of capability increased (P < .01; 95% CI = 2.73-6.72).

CONCLUSION

The data offer evidence for monthly triage meetings to transform the lives, deaths, and care of older people residing in care homes. J Am Geriatr Soc 68:305-312, 2020.

Nursing home staff members' knowledge, experience and attitudes regarding advance care planning: a cross-sectional study involving 12 Italian nursing homes

BACKGROUND

Advance care planning may be beneficial for nursing home residents, but its implementation is suboptimal in several countries.

AIMS

To investigate knowledge of, attitudes towards, and experience with advance care planning of nursing home staff members in Italy.

METHODS

Cross-sectional survey involving all healthcare professionals working in 12 Italian nursing homes. Statistical analyses investigated interactions between participants' characteristics, knowledge, attitudes and frequency of advance care planning discussion with residents.

RESULTS

Of the 185 participants (80.5% female, mean age 43.6 ± 9.2 years), 29.7% reported that they had heard of advance care planning, but their actual knowledge was suboptimal. Participants had positive attitudes towards advance care planning, and most of them clearly recognized its benefits. Apprehension about upsetting the patient or their family, or that patients were not ready for these conversations were the main concerns. Only 16% of respondents discussed advance care planning at least sometimes, usually upon patient/family input. Greater knowledge was significantly correlated with more positive attitudes towards advance care planning. The issues of healthcare professionals' knowledge and training in advance care planning, and of knowledge and awareness of advance care planning in patients, their families, and the general population were considered either main barriers or facilitators.

DISCUSSION

Nursing home staff members' concerns towards advance care planning seemed to be related to a misconception about patient and family willingness to discuss it.

CONCLUSIONS

A multifaceted strategy including educational and training programmes and the increase of public awareness is needed to implement advance care planning in Italian nursing homes.

Implementing advance care planning in routine nursing home care: The development of the theory-based ACP+ program

BACKGROUND

While various initiatives have been taken to improve advance care planning in nursing homes, it is difficult to find enough details about interventions to allow comparison, replication and translation into practice.

OBJECTIVES

We report on the development and description of the ACP+ program, a multi-component theory-based program that aims to implement advance care planning into routine nursing home care. We aimed to 1) specify how intervention components can be delivered; 2) evaluate the feasibility and acceptability of the program; 3) describe the final program in a standardized manner.

DESIGN

To develop and model the intervention, we applied multiple study methods including a literature review, expert discussions and individual and group interviews with nursing home staff and management. We recruited participants through convenience sampling.

SETTING AND PARTICIPANTS

Management and staff (n = 17) from five nursing homes in Flanders (Belgium), a multidisciplinary expert group and a palliative care nurse-trainer.

METHODS

The work was carried out by means of 1) operationalization of key intervention components-identified as part of a previously developed theory on how advance care planning is expected to lead to its desired outcomes in nursing homes-into specific activities and materials, through expert discussions and review of existing advance care planning programs; 2) evaluation of feasibility and acceptability of the program through interviews with nursing home management and staff and expert revisions; and 3) standardized description of the final program according to the TIDieR checklist. During step 2, we used thematic analysis.

RESULTS

The original program with nine key components was expanded to include ten intervention components, 22 activities and 17 materials to support delivery into routine nursing home care. The final ACP+ program includes ongoing training and coaching, management engagement, different roles and responsibilities in organizing advance care planning, conversations, documentation and information transfer, integration of advance care planning into multidisciplinary meetings, auditing, and tailoring to the specific setting. These components are to be implemented stepwise throughout an intervention period. The program involves the entire nursing home workforce. The support of an external trainer decreases as nursing home staff become more autonomous in organizing advance care planning.

CONCLUSIONS

The multicomponent ACP+ program involves residents, family, and the different groups of people working in the nursing home. It is deemed feasible and acceptable by nursing home staff and management. The findings presented in this paper, alongside results of the subsequent randomized controlled cluster trial, can facilitate comparison, replicability and translation of the intervention into practice.

Palliative care provision in long-term care facilities differs across Europe: Results of a cross-sectional study in six European countries (PACE)

BACKGROUND

While the need for palliative care in long-term care facilities is growing, it is unknown whether palliative care in this setting is sufficiently developed.

AIM

To describe and compare in six European countries palliative care provision in long-term care facilities and to assess associations between patient, facility and advance care planning factors and receipt and timing of palliative care.

DESIGN

Cross-sectional after-death survey regarding care provided to long-term care residents in Belgium, England, Finland, Italy, the Netherlands and Poland. Generalized estimating equations were used for analyses.

SETTING/PARTICIPANTS

Nurses or care assistants who are most involved in care for the resident.

RESULTS

We included 1298 residents in 300 facilities, of whom a majority received palliative care in most countries (England: 72.6%-Belgium: 77.9%), except in Poland (14.0%) and Italy (32.1%). Palliative care typically started within 2 weeks before death and was often provided by the treating physician (England: 75%-the Netherlands: 98.8%). A palliative care specialist was frequently involved in Belgium and Poland (57.1% and 86.7%). Residents with cancer, dementia or a contact person in their record more often received palliative care, and it started earlier for residents with whom the nurse had spoken about treatments or the preferred course of care at the end of life.

CONCLUSION

The late initiation of palliative care (especially when advance care planning is lacking) and palliative care for residents without cancer, dementia or closely involved relatives deserve attention in all countries. Diversity in palliative care organization might be related to different levels of its development.

Progress in advance care planning among nursing home residents dying with advanced dementia-Does it make any difference in end-of-life care?

BACKGROUND

Increased awareness of the clinical course of nursing home residents with advanced dementia and advance care planning (ACP) has become the cornerstone of good palliative care.

OBJECTIVE

The aim of our study is to describe changes in ACP in the form of physician treatment orders (PTOs), symptom prevalence and possible burdensome interventions among nursing home (NH) residents who died between 2004-2009 and 2010-2013 METHODS: Retrospective study RESULTS: The number of PTOs regarding forgoing antibiotics or parenteral antibiotics, forgoing artificial nutrition or hydration or forgoing hospitalisation doubled between 2004-2009 and 2010-2013 (38.1% vs. 64.9%, p < 0.001; 40.0% vs. 81.7%, p < 0.001; 28.1% vs. 69.5%, p < 0.001, respectively). PTOs were also done significantly earlier in 2010-2013 than in 2004-2009. The prevalence of distressing symptoms and possible burdensome interventions remained unchanged, although the prevalence of consistency with the PTOs was high.

CONCLUSION

Despite the increased number of PTOs, this had little effect on symptom prevalence and possible burdensome interventions experienced by NH residents in the last days of life.

Preventable hospitalizations from ambulatory care sensitive conditions in nursing homes: evidence from Switzerland

OBJECTIVES

Reducing nursing home hospitalizations for ambulatory care sensitive conditions (ACSC) has been identified as an opportunity to improve patient well-being and reduce costs. The aim of this study was to identify number of hospitalizations for ACSCs for nursing home residents in a Swiss national sample, examine demographic characteristics of nursing home hospitalizations due to ACSCs, and calculate hospital expenses from these hospitalizations.

METHODS

Using merged hospital administrative data with payment data based on diagnosis-related groups (DRGs) for the year 2013, we descriptively examined nursing home residents who were 65 years of age or older and were admitted to an acute care hospital.

RESULTS

Approximately 42% of all nursing home admissions were due to ACSCs. Payments to Swiss hospitals for ACSCs can be estimated at between 89 and 105 million Swiss francs in 2013.

CONCLUSIONS

A sizable share of hospitalizations for nursing home residents is for ACSCs, and the associated costs are substantial. Programs and policies designed to reduce these potentially avoidable hospitalizations from the nursing home setting could lead to an increased patient well-being and lower costs.

Frailty, Hospitalization, and Mortality in Residential Aged Care

Background

Frailty predicts mortality in residential aged care, but the relationship with hospitalization is inconsistent. The purpose of this study was to investigate and compare whether frailty is associated with hospitalization and mortality among residents of aged care services.

Methods

A prospective cohort study of 383 residents aged 65 years and older was conducted in six Australian residential aged care services. Frailty was assessed using the FRAIL-NH scale and a 66-item frailty index.

Results

Overall, 125 residents were hospitalized on 192 occasions and 85 died over the 12-month follow-up. Over this period, less than 3% of the nonfrail/vulnerable residents but more than 20% of the most frail residents died at the facility without hospitalization. Using the FRAIL-NH, residents with mild/moderate frailty had higher numbers of hospitalizations (adjusted incidence rate ratio 1.57, 95% confidence interval [CI] 1.11-2.20) and hospital days (incidence rate ratio 1.48, 95% CI 1.32-1.66) than nonfrail residents. Residents who were most frail had lower numbers of hospitalizations (incidence rate ratio 0.65, 95% CI 0.42-0.99) and hospital days (incidence rate ratio 0.39, 95% CI 0.33-0.46) than nonfrail residents. Similar patterns of associations with number of hospital days were observed for the frailty index. Most frail residents had a higher risk of death than nonfrail residents (for FRAIL-NH, adjusted hazard ratio 2.96, 95% CI 1.50-5.83; for frailty index, hazard ratio 5.28, 95% CI 2.05-13.59).

Conclusions

Residents with mild/moderate frailty had higher risk of hospitalization and death than nonfrail residents. Residents who were most frail had higher risk of death but lower risk of hospitalization than nonfrail residents.

Introducing Goals of Patient Care in Residential Aged Care Facilities to Decrease Hospitalization: A Cluster Randomized Controlled Trial

OBJECTIVES

The "Goals of Patient Care" (GOPC) process uses shared decision making to incorporate residents' prior advance care planning (ACP) or preferences into medical treatment orders, guiding health care decisions at a time of clinical deterioration should they be unable to voice their opinions. The objective was to determine whether GOPC medical treatment orders were more effective than ACP alone in preventing emergency department (ED) visits (no hospitalization), ED visits (with hospitalization), and deaths outside the residential aged care facility (RACF).

DESIGN

The study was a prospective cluster randomized controlled trial, with the intervention being the completion of GOPC process by a geriatrician, following a shared decision-making process, incorporating ACP documents or residents' preferences.

SETTING AND PARTICIPANTS

The study took place in 6 RACFs in Northern Metropolitan Melbourne, Australia. Eligible participants included all permanent residents in participating RACFs for whom written informed consent could be obtained.

MEASURES

The primary outcome was the effect on ED visits and hospitalizations at 6 months. Secondary outcomes included a difference in hospitalization rates at 3 and 12 months, total hospital bed-days, and in-RACF and in-hospital mortality rates.

RESULTS

More than 75% of residents participated, 181 randomized to Intervention and 145 to Control. The intervention did not result in a statistically significant change at 6 months; however, at 12 months, it reached statistical significance with 40% reduction in ED visits and hospitalizations compared with Control, with an incident rate ratio 0.63 [95% confidence interval (CI) 0.41-0.99, P = .044]. Mortality rates show increased likelihood of dying in the RACF, with statistical significance at 6 months at a relative risk ratio of 2.19 (95% CI 1.16-4.14, P = .016).

CONCLUSIONS AND IMPLICATIONS

In the RACF population, GOPC medical treatment orders were more effective than ACP alone for decreasing hospitalization and likelihood of dying outside the RACF. GOPC should be considered by both RACF staff and health services to decrease hospitalization and in-hospital mortality.

Are older and seriously ill inpatients planning ahead for future medical care?

Background

Despite the perceived ethical, personal and health service benefits of advance care planning (ACP), the extent to which older and seriously ill Australian inpatients have considered future health decisions remains uncertain. This study aimed to determine in a sample of older and seriously ill inpatients, the proportion who had: 1) engaged in four advance care planning (ACP) activities; 2) not engaged in ACP activities but wanted to; and 3) reasons why they had not engaged.

Methods

Cross-sectional face-to-face standardised interview survey with inpatients in a tertiary referral centre who were either: aged 80+ years; aged 55+ years with progressive chronic disease(s); or judged by treating clinicians as having a life expectancy of less than 12 months. Patients indicated whether they had engaged in four ACP activities: (1) appointed medical substitute-decision-maker(s), (2) recorded end-of-life wishes in an advance directive or care plan; and talked about their end-of-life wishes with their: (3) support persons and/or (4) doctors. Patients who had not engaged in activities were asked whether they wished this to occur and reasons why.

Results

One hundred eighty-six inpatients consented to the study (80% of approached). Of these, 9% (n = 16) had engaged in four ACP activities; 27% (n = 50) had not engaged in any. Half (n = 94, 52%) had appointed a medical substitute-decision-maker, 27% (n = 50) had recorded wishes in an advance directive or care plan, 51% (n = 90) had talked about their end-of-life wishes with support persons and 27% (n = 48) had talked with their doctor. Patients who wanted to, but had not, engaged in the four ACP activities were unaware they could record wishes or appoint decision-makers, or indicated providers had not initiated conversations.

Conclusion

Relatively few inpatients had engaged in all four ACP activities. More inpatients had discussed end of life issues with family and appointed substitute decision makers, than completed written documents or talked with doctors. Community education and a more active role for community and hospital-based providers in supporting patients and families to collaboratively resolve end-of-life decisions may increase the probability wishes are known and followed.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1211-2) contains supplementary material, which is available to authorized users.

Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting

Background

The PRagmatic trial Of Video Education in Nursing homes (PROVEN) aims to test the effectiveness of an advance care planning (ACP) video intervention. Relatively little is known about the challenges associated with implementing ACP interventions in the nursing home (NH) setting, especially within a pragmatic trial. To address this research gap, this report sought to identify facilitators of and barriers to implementing PROVEN from the perspective of the Champions charged with introducing the ACP video program delivery to patients and families.

Methods

In semi-structured telephone interviews at 4 and 15 months of the 18-month implementation period, ACP Champions at all PROVEN intervention facilities (N = 119) were asked about their perceptions of program implementation. Forty interviews were purposively sampled, transcribed, and analyzed using a hybrid deductive/inductive approach to thematic analysis incorporating the Consolidated Framework for Implementation Research’s domains: Intervention Characteristics (IC), Inner Setting (IS), Characteristics of Individuals (CI), Outer Setting (OS), and Process (P).

Results

Implementation facilitators identified by Champions included: the intervention’s adaptable mode of presentation and minimal time burden (IC) as well as the program’s customizable delivery to patients and families and opportunity for group reflection on implementation among ACP Champions (P). Barriers included mandated protocol-driven aspects of the program (OS), limited time to deliver the intervention (IS), and lack of perceived relevance and emotional readiness for ACP amongst stakeholders (CI).

Conclusions

Despite the promise of PROVEN’s intervention for improving ACP in nursing homes, unchangeable setting and characteristics of Champions, patients, and family members presented implementation barriers. Researchers need to engage all program participants (i.e., facility staff, patients, and families), in addition to corporate-level stakeholders, in early pragmatic trial design to minimize such obstacles. Further, despite the facilitating nature of PROVEN’s implementation processes, the study encountered tension between scientific rigor and real-world demands. Researchers need to optimize the real-world authenticity of pragmatic trial design while avoiding excessive implementation protocol deviations.

Trial registration

ClinicalTrials.gov Identifier: NCT02612688. Registered 19 November 2015.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4309-5) contains supplementary material, which is available to authorized users.

Balancing between maintaining and overriding the self: Staff experiences of residents' self-determination in the palliative phases

AIMS AND OBJECTIVES

To investigate, from the staff perspective, residents' self-determination during the palliative phase while in residential care.

BACKGROUND

Residential care facilities have a high prevalence of palliative care needs and dependency. The ability of residents to make and execute decisions may be hindered by their cognitive and physical limitations. There is a need to investigate how residents' self-determination is affected during the palliative phase in residential care.

METHOD

Twenty individual, semi-structured interviews with Registered Nurses, enrolled nurses and physicians working in residential care facilities were analysed with inductive qualitative content analysis.

FINDINGS

The overarching main theme, Balancing between maintaining and overriding the residents' self, illuminated how strengthened self-determination affected the residents' self in a positive way, while undermined self-determination affected the residents' self in a negative way. Factors that strengthened self-determination were facilitating the residents' own decision making, acting in accordance with the residents' wishes and acting as the residents' spokesperson when necessary. Factors that undermined self-determination were residents' dependence, others setting the terms, for example, being controlled by routines, insufficient communication, for example, lacking end-of-life care planning and others crossing the boundaries of one's personal sphere.

CONCLUSION

There are serious threats to residents' self-determination but also strategies to cope with these threats. Physical and cognitive frailty and other people setting the terms hinder both making and executing decisions. However, staff can strengthen residents' self-determination and assist in the presentation of residents' self by adopting a relational view of autonomy and by taking personal preconditions into account. There is a need to come to terms with the lack of end-of-life care planning and to give residents a voice in these matters. Implementing a palliative approach early in the illness trajectory could facilitate communication about end-of-life care both within the group of staff and among the residents, relatives and staff.

IMPLICATIONS FOR PRACTICE

To maintain residents' self-determination and protect their self, staff need knowledge about residents' life stories and personal preconditions. This in turn requires continuity of care and spending time with residents to build relationships. Implementing an early palliative approach with a focus on factors that promote quality of life for each resident might facilitate communication and enhance decision making both in everyday life and in planning for end-of-life care.

CE: Original Research: Advance Care Planning: An Exploration of the Beliefs, Self-Efficacy, Education, and Practices of RNs and LPNs

: Objective: This study compared the advance care planning (ACP)-related beliefs, sense of self-efficacy, education, and practices of RNs and LPNs.

METHODS

Data were extrapolated from a larger multisite study that was conducted across seven counties in one midwestern state. The sample consisted of RNs and LPNs working in 29 urban skilled nursing facilities in zip code areas with greater than 10% African American residents. The survey tool, a self-administered written questionnaire, gathered data on participants' demographics and ACP-related beliefs, sense of self-efficacy, education, and practices. The two main outcome variables were the percentage of residents with whom a nurse discussed ACP and the timing of the most recent such discussion.

RESULTS

A total of 136 RNs and 178 LPNs completed the survey. Multivariate mixed-model analysis of the two main outcome variables showed that negative beliefs were not significantly associated with the percentage of residents with whom nurses discussed ACP but were significantly associated with the timing of the most recent ACP discussion. Having higher levels of ACP-related self-efficacy and education were significantly and positively associated with both outcome variables. RNs and LPNs did not differ significantly in their ACP-related beliefs, but RNs reported significantly higher levels of self-efficacy and education than LPNs did.

CONCLUSIONS

There has been a paucity of research comparing RNs and LPNs regarding their ACP practices in skilled nursing facilities. Better education and policies that empower nurses to take a more active role are critical to increasing conversations about ACP. Further research exploring how the complementary roles of RNs and LPNs can be used to improve ACP processes and inform ACP policies is needed.

Care Transitions Program for High-Risk Frail Older Adults is Most Beneficial for Patients with Cognitive Impairment

BACKGROUND

Although posthospitalization care transitions programs (CTP) are highly diverse, their overall program thoroughness is most predictive of their success.

OBJECTIVE

To identify components of a successful homebased CTP and patient characteristics that are most predictive of reduced 30-day readmissions.

DESIGN

Retrospective cohort.

PATIENTS

A total of 315 community-dwelling, hospitalized, older adults (≥60 years) at high risk for readmission (Elder Risk Assessment score ≥16), discharged home over the period of January 1, 2011 to June 30, 2013.

SETTING

Midwest primary care practice in an integrated health system.

INTERVENTION

Enrollment in a CTP during acute hospitalization.

MEASUREMENTS

The primary outcome was all-cause readmission within 30 days of the first CTP evaluation. Logistic regression was used to examine independent variables, including patient demographics, comorbidities, number of medications, completion, and timing of program fidelity measures, and prior utilization of healthcare.

RESULTS

The overall 30-day readmission rate was 17.1%. The intensity of follow-up varied among patients, with 17.1% and 50.8% of the patients requiring one and ≥3 home visits, respectively, within 30 days. More than half (54.6%) required visits beyond 30 days. Compared with patients who were not readmitted, readmitted patients were less likely to exhibit cognitive impairment (29.6% vs 46.0%; P = .03) and were more likely to have high medication use (59.3% vs 44.4%; P = .047), more emergency department (ED; 0.8 vs 0.4; P = .03) and primary care visits (4.0 vs 3.0; P = .018), and longer cumulative time in the hospital (4.6 vs 2.5 days; P = .03) within 180 days of the index hospitalization. Multivariable analysis indicated that only cognitive impairment and previous ED visits were important predictors of readmission.

CONCLUSIONS

No single CTP component reliably predicted reduced readmission risk. Patients with cognitive impairment and polypharmacy derived the most benefit from the program.

Significance of advance care planning in nursing homes: views from patients with cognitive impairment, their next of kin, health personnel, and managers

Purpose: Advance care planning (ACP) performed by regular staff, which also includes patients with cognitive impairment and their next of kin, is scarcely studied. Thus, we planned an implementation study including key stakeholders (patients, next of kin, and health care personnel) using a whole-ward/system approach to ACP. We explored how they experienced ACP and its significance.

Patients and methods: This qualitative study is part of a mixed-method implementation study of ACP. In four nursing homes, we did qualitative interviews and audio-recordings of meetings. We completed 20 individual semistructured interviews with participants soon after ACP conversations. The interviews included patients with cognitive impairment, their next of kin, and health care personnel. We also conducted four focus group interviews with staff and managers in the nursing homes and audio-recorded four network meetings with the project teams implementing ACP.

Results: All participants appreciated taking part in ACP. Patients and next of kin focused more on the past and present than future treatment preferences. Still, ACP seemed to contribute to a stronger patient focus on end-of-life conversations. More generally, ACP seemed to contribute to valuable information for future decision-making, trusting relations, improved end-of-life communication, and saving time and resources.

Conclusion: Safeguarding a strong patient focus on ACP and fostering a person-centered care culture in nursing home wards seem to be achievable through implementation of ACP that includes regular staff, patients with cognitive impairment, and their next of kin.

Pragmatic methods to avoid intensive care unit admission when it does not align with patient and family goals

For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.

Integrated Palliative Care for Nursing Home Residents: Exploring the Challenges in the Collaboration between Nursing Homes, Home Care and Hospitals

INTRODUCTION

Nursing home residents are a vulnerable and frail segment of the population, characterised by their complex and palliative care needs. To ensure an integrated approach to palliative care for this target group, working on a collaborative basis with multiple providers across organisational boundaries is necessary. Considering that coordinators of palliative networks support and coordinate collaboration, the research question is: 'how do network coordinators perceive the process of collaboration between organisations in Flemish palliative networks?'

METHODS

A dual-phase sequential mixed-methods design was applied. First, the coordinators of each of the fifteen palliative networks in Flanders completed a survey in which they evaluated ten aspects of collaboration for two types of cooperation: between nursing homes and home care, and between nursing homes and hospitals. Next, the survey results thus obtained were discussed to improve understanding in a focus group composed of the above coordinators, and which was analysed on the basis of content analysis.

RESULTS

In both forms of cooperation, the 'formalisation' and 'governance' were the aspects that yielded the lowest mean scores. The coordinators in the focus group expressed a need for more formalised interaction among organisations with regard to palliative care, the establishment of formal channels of communication and the exchange of information, as well as the development of shared leadership.

CONCLUSIONS

The perspectives of the coordinators on inter-organisational collaboration are a valuable starting point for interventions directed at the stronger integration of palliative care for residents of long term-care facilities.

Facilitators and barriers to advance care planning implementation in Australian aged care settings: A systematic review and thematic analysis

OBJECTIVES

There are many studies investigating implementation of advance care planning (ACP) in aged care around the world, but few studies have investigated Australian settings. The objective of this study was to determine facilitators and barriers to implementation of ACP in Australian residential and community aged care.

METHODS

Evidence from Australian studies published between 2007 and September 2017 of ACP in residential and community aged care was sourced from electronic databases using predetermined search strategies. Data were extracted and synthesised using thematic analysis, and summarised according to themes.

RESULTS

Nine studies described facilitators and barriers of ACP implementation. Six themes were identified: "Education and Knowledge," "Skills and Training," "Procedures and Resources," "Perceptions and Culture," "Legislation" and "Systems."

CONCLUSIONS

A whole of systems approach is necessary to facilitate uptake of ACP in residential aged care settings. More research is needed to understand facilitators and barriers to ACP in community aged care.

Advance Care Planning in Skilled Nursing Facilities: A Multisite Examination of Professional Judgments

BACKGROUND AND OBJECTIVES

Lack of advance care planning (ACP) may increase hospitalizations and impact the quality of life for skilled nursing facility (SNF) residents, especially African American residents who may be less likely to receive ACP discussions. We examined the professional judgments of SNF providers to see if race of SNF residents and providers, and risk for hospitalization for residents influenced professional judgments as to when ACP was needed and feelings of responsibility for ensuring ACP discussions.

RESEARCH DESIGN AND METHODS

Nurses and social workers (n = 350) within 29 urban SNFs completed surveys and rated vignettes describing eight typical SNF residents. Linear mixed modeling was used to examine factors that impacted ratings of need for ACP and responsibility for ensuring ACP.

RESULTS

Neither the race of the provider, resident, nor the interaction of the two were associated with either outcome variable. In contrast, providers rated (on a 9-point scale) residents at high risk for hospitalization as more in need of ACP (estimate = 0.86, confidence interval [CI] 0.65, 1.07) and felt more responsible for ensuring ACP (estimate = 0.60, CI 0.42, 0.78).

DISCUSSION AND IMPLICATIONS

Research on ACP is continuing to evolve and these results show the primacy of disease trajectory variables on providers' judgments about ACP. Differences between providers indicate a need for stronger policies and education. Further, research comparing rural, suburban, and urban SNFs is needed to explore possible forms of structural racism such as residential and SNF segregation.

Advance care planning for home health staff: a systematic review

BACKGROUND

Advance care planning (ACP) is a process where patients express their wishes regarding their future healthcare. Its importance has been increasingly recognised in the past decade. As increasing numbers of elderly people are living in care homes, the aim of this review was to identify the most effective ACP interventions to train/educate all levels of healthcare professionals working in care homes.

DESIGN

A systematic review. Two independent reviewers undertook screening, data extraction and quality assessment.

DATA SOURCES

 Searched from inception to June 2018: Ovid Medline, Ovid Medline in process, Ovid Embase, Cochrane Central Register of Controlled Trials, EBSCO Cinahl and Ovid PsycINFO.

RESULTS

Six studies were included: three before and after studies, one cluster randomised controlled trial (RCT), one non-blinded RCT and one qualitative study. Five studies reported on ACP documentation, three on impact on ACP practice and three studies on healthcare-related outcomes. All quantitative studies reported an improvement in outcomes. In the three studies reporting on health-related outcomes, one showed significant reductions in hospitalisation rate, days and healthcare costs; one reported significant reductions in hospital deaths; and the third showed reductions in hospital days and deaths. A meta-analysis could not be performed due to the heterogeneity of the outcome measures. The included qualitative study highlighted perceived challenges to implementing an educational programme in the care home setting.

CONCLUSION

There is limited evidence for the effectiveness of ACP training for care home workers. More well-designed studies are needed.

TRIAL REGISTRATION NUMBER

CRD42016042385 .

Retrospective cohort analysis of real-life decisions about end-of-life care preferences in a Southeast Asian country

OBJECTIVE

To describe the end-of-life care preferences of individuals, and to examine the influence of age and gender on these preferences.

DESIGN, SETTING AND PARTICIPANTS

A retrospective cohort study was conducted. Participants included all adults (≥21 years old) (n=3380) who had completed a statement of their preferences as part of a national Advance Care Planning (ACP) programme in Singapore. Data were extracted from the national and Tan Tock Seng Hospital ACP database.

MAIN MEASURES

End-of-life care preferences were obtained from the ACP document and differentiated by health status (healthy, chronically ill or diagnosed with advanced illnesses). To analyse the data, descriptive statistics and logistic regression analysis were used.

RESULTS

Across healthy and chronically ill patients, the majority did not opt for cardiopulmonary resuscitation (CPR) or other life-sustaining measures. Among individuals with advanced illnesses, 94% preferred not to attempt CPR but 69% still preferred to receive some form of active medical treatment. Approximately 40% chose to be cared for, and to die at home. Age and sex significantly predict preferences in those with advanced illnesses. Older age (>=75 years) showed higher odds for home as preferred place of care (OR 1.52; 95% CI 1.23 to 1.89) and place of death (OR 1.29; 95% CI 1.03 to 1.61) and lower odds for CPR (OR 0.31; 95% CI 0.18 to 0.54) and full treatment (OR 0.32; 95% CI 0.17 to 0.62). Being female was associated with lower odds for home as preferred place of care (OR 0.69; 95% CI 0.57 to 0.84) and place of death (OR 0.70; 95% CI 0.57 to 0.85) and higher odds for full treatment (OR 2.35; 95% CI 1.18 to 4.68).

CONCLUSION

The majority preferred to not proceed with life-sustaining treatments, but there was still a strong preference to receive some form of limited treatment. Better understanding of end-of-life care preferences through ACP can better guide end-of-life care programme planning, and resource allocation decisions.

Prevalence and correlates of advance care directives among older Australians accessing health and residential aged care services: multicentre audit study

OBJECTIVES

It is important that the outcomes of advance care planning (ACP) conversations are documented and available at the point of care. Advance care directives (ACDs) are a subset of ACP documentation and refer to structured documents that are completed and signed by competent adults. Other ACP documentation includes informal documentation by the person or on behalf of the person by someone else (eg, clinician, family). The primary objectives were to describe the prevalence and correlates of ACDs among Australians aged 65 and over accessing health and residential aged care services. The secondary aim was to describe the prevalence of other ACP documentation.

DESIGN AND SETTING

A prospective multicentre health record audit in general practices (n=13), hospitals (n=12) and residential aged care facilities (RACFs; n=26).

PARTICIPANTS

503 people attending general practice, 574 people admitted to hospitals and 1208 people in RACFs.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of one or more ACDs; prevalence of other ACP documentation.

RESULTS

29.8% of people had at least one ACD on file. The majority were non-statutory documents (20.9%). ACD prevalence was significantly higher in RACFs (47.7%) than hospitals (15.7%) and general practices (3.2%) (p<0.001), and varied across jurisdictions. Multivariate logistic regression showed that the odds of having an ACD were positively associated with greater functional impairment and being in an RACF or hospital compared with general practice. 21.6% of people had other ACP documentation.

CONCLUSIONS

In this study, 30% of people had ACDs accessible and a further 20% had other ACP documentation, suggesting that approximately half of participants had some form of ACP. Correlates of ACD completion were greater impairment and being in an RACF or hospital. Greater efforts to promote and standardise ACDs across jurisdictions may help to assist older people to navigate and complete ACDs and to receive care consistent with their preferences.

TRIAL REGISTRATION NUMBER

ACTRN12617000743369.

Assessing concordance between patient preferences in advance care plans and in-hospital care

Objective The aims of this study were to assess: (1) concordance between patient preferences stated in advance care plans (ACPs) and hospital care over the subsequent 12 months; (2) change in preferences over time; (3) justifications for discordant care; and (4) effects of ACP completion on hospital utilisation. Methods A retrospective study was conducted of 198 patients with an ACP form registered with an ACP registry and tagged with a hospital unique record number. Data collected from ACP forms and hospital records comprised ACP completion and revisions, care preferences, patient characteristics and hospital care. Instances of care discordant with preferences were analysed as Type A (no ascertainable justification) and Type B (direct patient request or appropriate clinical indications). In a survivor subset, hospital utilisation was compared before and after ACP completion. Results Mean (± s.d.) patient age was 79.5±11.8 years. Patients had a mean (± s.d.) of 5.5±2.5 comorbidities and 90 (46.4%) died within the 12 months after ACP completion. Most ACPs (130; 65.5%) were completed during index hospitalisation and 13 (6.5%) underwent revision, on average, 6.8 months later, all related to rescinding request for cardiopulmonary resuscitation. Hospital care was fully concordant for 154 (77.8%) patients, with 39 (22.2%) receiving 60 instances of discordant care (15 (25%) Type A, 45 (75%) Type B), mostly related to surgical procedures (20; 33%) and intravenous fluids or antibiotics (26; 43%). Patients receiving discordant care had higher mortality (77% vs 45%; P&lt;0.001) and more rapid response team activations (34% vs 13%; P=0.001) at 12 months than patients with concordant care. Among the 108 confirmed survivors at 12 months after ACP completion, emergency department presentations and hospital admissions per patient had decreased by ≥50% (P&lt;0.001) and hospital days had decreased by 25% (P=0.042) compared with the 12 months before ACP completion. Conclusion Most patients completing an ACP received hospital care fully concordant with their stated preferences, with few revising their preferences over time. Discordant care mostly related to justified supportive treatments or surgical procedures. Among survivors, ACP completion was associated with decreased use of hospital care. What is known about the topic? ACPs that list patient preferences and care goals relieve family and patient distress and uncertainty regarding future care decisions as death approaches, decrease unwanted medical interventions and hospitalisations, and are associated with more patients dying at home. However, uncertainty surrounds the extent to which in-patient care provided to patients’ concords with preferences stated in ACPs, which preferences are most adhered to, and whether preferences change over time, warranting revision of ACPs. What does this paper add? This retrospective study of 198 patients completing an ACP, of whom almost half died within the following 12 months, showed that more than 75% received hospital care fully concordant with their stated preferences and, for decedents, most died at their preferred place of death. Relatively few patients changed their documented preferences over time, and all changes were for less use of cardiopulmonary resuscitation (CPR). Instances of discordant care mostly related to the administration of supportive treatments or surgical procedures and most were justified on the basis of patient request or appropriate clinical indications. Among 108 survivors, the number of emergency department presentations and hospital admissions per patient at 12 months after ACP completion was half those seen in the 12 months before ACP completion, whereas hospital days per patient decreased by 25%. What are the implications for practitioners? Encouraging patients with progressive chronic disease to complete an ACP reduces their risk of receiving care they do not want, reflected in decreased use of hospital care. Preferences stated in ACPs are mostly stable over time and, if changed, tend to become more conservative in terms of CPR. Conversely, preferences stated in the ACP do not, as circumstances change, bind patients or clinicians to withholding care that relieves symptoms or prevents major morbidity in the short term.

The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials

BACKGROUND:

No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced cancer, and the mechanisms of action in relation to the intended outcomes.

AIM:

To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes.

DESIGN:

A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative synthesis was used for data analysis.

DATA SOURCES:

The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality appraisal.

RESULTS:

Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which advance care planning improved outcomes comprised (1) increasing patients' knowledge of end-of-life care, (2) strengthening patients' autonomous motivation, (3) building patients' competence to undertake end-of-life discussions and (4) enhancing shared decision-making in a trustful relationship. Samples were largely highly educated Caucasian.

CONCLUSION:

The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they identify the individual behavioural change. Strengthening patients' motivation and competence in participating advance care planning discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and ethnicities in non-Western countries should be a research priority.

Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study

AIM

To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents.

METHODS

A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools.

RESULTS

ACP was never initiated during the 2-year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid-modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid-modifying agents was not associated with ACP.

CONCLUSIONS

The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision-making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life. Geriatr Gerontol Int 2019; 19: 141-146.

Advance Care Planning in Nursing Homes - Improving the Communication Among Patient, Family, and Staff: Results From a Cluster Randomized Controlled Trial (COSMOS)

Introduction: The majority of nursing home (NH) patients suffer from complex diseases, including dementia. This makes advance care planning (ACP) particularly important.

Objectives: The aim was to investigate the effect of an ACP intervention on communication among NH staff, patient, and family. We further investigated whether the intervention affected nursing staff distress.

Methods: The ACP intervention was a part of the 4-month cluster randomized controlled COSMOS trial with a 9-month follow-up. Norwegian NH units (n = 72), with 765 patients were invited, and eligible units were cluster randomized to usual care or the intervention group. The ACP intervention consisted of an education program targeting all NH staff (nurses and physicians) and managers. Implementation was supported by a train-the-trainer approach, with regular phone calls from the researchers. The effect of the intervention was assessed by a data collection form and questionnaires. Nursing staff distress was assessed by the Neuropsychiatric Inventory -Nursing Home version.

Results: Five hundred and forty five patients from 67 NH units were included and randomized to the intervention (N = 297; 36 units) and control group (N = 248; 31 units). Organized meetings between the family, patient, and nurses were conducted more frequently in the intervention compared to the control group at month 4 (OR = 3.9, 95% CI = 1.6 to 9.4, p = 0.002). Monthly contact between family and nurses was also more frequent in the intervention group (OR = 6.5, 95% CI = 1.6 to 3.5, p = 0.010). Nurses and families were more satisfied with their communication in the intervention compared to the control group. Staff distress was reduced in the intervention group at month 4 (B = -1.8, 95% CI = -3.1 to -0.4, p = 0.012). The intervention effect at month 4 did not persist during follow-up at month 9.

Conclusion: Compared to control, the ACP intervention improved the communication, and family and staff satisfaction as well as reduced staff distress. However, during the follow-up period these positive effects were not persistent. Indicating the necessity for ongoing staff support regarding ACP.

Trial Registration:www.ClinicalTrials.gov (NCT02238652).

Effect of Living Wills on End-of-Life Care: A Systematic Review

OBJECTIVES

To comprehensively assess the effect of a living will on end-of-life care.

DESIGN

Systematic review with narrative analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology.

PARTICIPANTS

All interventional and observational studies were included, excepting those with fictive cases. Included studies were conducted in adults with and without living wills, excluding individuals with specific psychiatric living wills.

MEASUREMENTS

Two authors independently extracted study and participant characteristics and outcomes related to end-of-life care (place of death, hospitalization and intensive care unit management, life-sustaining treatments, restricted care). Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions tool.

RESULTS

From 7,596 records identified, 28 observational studies were included, 19 conducted in the United States, 7 in Europe, and 1 each in Canada and Australia. Place of death was assessed in 14 studies, life-sustaining treatments in 13, decision for restricted care in 12, and hospitalization in 8. Risk of bias was serious for 26 studies and moderate for 2. Twenty-one studies reported significantly less medical management for individuals with a living will, 3 reported more medical management, and the difference was not significant in 37.

CONCLUSION

Methodological quality of included studies was insufficient to offer reliable results. The effect of living wills appears limited in view of the importance and direction of potential biases. Further studies including larger populations, considering main confounding factors, and documenting the real presence of a living will in medical records are necessary to reach stronger conclusions on the effect of living wills on end-of-life care. J Am Geriatr Soc 67:164-171, 2019.

Advance Care Planning in the Nursing Home Setting: A Practice Improvement Evaluation

This study evaluated a practice improvement initiative conducted over a 6 month period in 15 Canadian nursing homes. Goals of the initiative included: (1) use the Plan-Do-Study-Act (PDSA) model to improve advance care planning (ACP) within the sample of nursing homes; (2) investigate whether improved ACP practice resulted in a change in residents' hospital use and ACP preferences for home-based care; (3) engage participating facilities in regular data collection to inform the initiative and provide a basis for reflection about ACP practice and; (4) foster a team-based participatory care culture. The initiative entailed two cycles of learning sessions followed by implementation of ACP practice improvement projects in the facilities using a PDSA approach by participating clinicians (e.g., physicians, social workers, nurses). Clinicians reported significantly increased confidence in many dimensions of ACP activities. Rates of hospital use and resident preference for home-based care did not change significantly. The initiative established routine data collection of outcomes to inform practice change, and successfully engaged physicians and non-physician clinicians to work together to improve ACP practices. Results suggest recurrent PDSA cycles that engage a 'critical mass' of clinicians may be warranted to reinforce the standardization of ACP in practice.

Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons

BACKGROUND

Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians.

AIM

The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice.

DESIGN

An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool.

DATA SOURCES

MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis.

RESULTS

Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders.

CONCLUSIONS

Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.

A Framework to Guide Economic Analysis of Advance Care Planning

BACKGROUND

Advance care planning (ACP) is fundamental to guiding medical care at the end of life. Understanding the economic impact of ACP is critical to implementation, but most economic evaluations of ACP focus on only a few actors, such as hospitals.

OBJECTIVE

To develop a framework for understanding and quantifying the economic effects of ACP, particularly its distributional consequences, for use in economic evaluations.

DESIGN

Literature review of economic analyses of ACP and related costs to estimate magnitude and direction of costs and benefits for each actor and how data on these costs and benefits could be obtained or estimated.

RESULTS

ACP can lead to more efficient allocation of resources by reducing low-value care and reallocating resources to high-value care, and can increase welfare by aligning care to patient preferences. This economic framework considers the costs and benefits of ACP that accrue to or are borne by six actors: the patient, the patient's family and caregivers, healthcare providers, acute care settings, subacute and home care settings, and payers. Program implementation costs and nonhealthcare costs, such as time costs borne by patients and caregivers, are included. Findings suggest that out-of-pocket costs for patients and families will likely change if subacute or home care is substituted for acute care, and subacute care utilization is likely to increase while primary healthcare providers and acute care settings may experience heterogeneous effects.

CONCLUSIONS

A comprehensive economic evaluation of ACP should consider how costs and benefits accrue to different actors.

State of advance care planning research: A descriptive overview of systematic reviews

OBJECTIVE

To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes.

METHOD

Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches.

RESULT

Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes.

SIGNIFICANCE OF RESULTS

Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.

Advance Care Planning for Older People with Cancer and Its Implications in Asia: Highlighting the Mental Capacity and Relational Autonomy

With dramatically increasing proportions of older people, global ageing has remarkably influenced healthcare services and policy making worldwide. Older people represent the majority of patients with cancer, leading to the increasing demand of healthcare due to more comorbidities and inherent frailty. The preference of older people with cancer are often ignored, and they are considered incapable of making choices for themselves, particularly medical decisions. This might impede the provision of their preferred care and lead to poor healthcare outcomes. Advance care planning (ACP) is considered an effective intervention to assist older people to think ahead and make a choice in accordance with their wishes when they possess capacity to do so. The implementation of ACP can potentially lead to positive impact for patients and families. However, the assessment of mental capacity among older adults with cancer might be a crucial concern when implementing ACP, as loss of mental capacity occurs frequently during disease deterioration and functional decline. This article aims to answer the following questions by exploring the existing evidence. How does ACP develop for older people with cancer? How can we measure mental capacity and what kind of principles for assessment we should apply? What are the facilitators and barriers when implementing an ACP in this population? Furthermore, a discussion about cultural adaptation and relevant legislation in Asia is elucidated for better understanding about its cultural appropriateness and the implications. Finally, recommendations in relation to early intervention with routine monitoring and examination of capacity assessment in clinical practice when delivering ACP, reconciling patient autonomy and family values by applying the concept of relational autonomy, and a corresponding legislation and public education should be in place in Asia. More research on ACP and capacity assessment in different cultural contexts and policy frameworks is highlighted as crucial factors for successful implementation of ACP.

Advance care planning in dementia: recommendations for healthcare professionals

Background

Advance care planning (ACP) is a continuous, dynamic process of reflection and dialogue between an individual, those close to them and their healthcare professionals, concerning the individual’s preferences and values concerning future treatment and care, including end-of-life care. Despite universal recognition of the importance of ACP for people with dementia, who gradually lose their ability to make informed decisions themselves, ACP still only happens infrequently, and evidence-based recommendations on when and how to perform this complex process are lacking. We aimed to develop evidence-based clinical recommendations to guide professionals across settings in the practical application of ACP in dementia care.

Methods

Following the Belgian Centre for Evidence-Based Medicine’s procedures, we 1) performed an extensive literature search to identify international guidelines, articles reporting heterogeneous study designs and grey literature, 2) developed recommendations based on the available evidence and expert opinion of the author group, and 3) performed a validation process using written feedback from experts, a survey for end users (healthcare professionals across settings), and two peer-review groups (with geriatricians and general practitioners).

Results

Based on 67 publications and validation from ten experts, 51 end users and two peer-review groups (24 participants) we developed 32 recommendations covering eight domains: initiation of ACP, evaluation of mental capacity, holding ACP conversations, the role and importance of those close to the person with dementia, ACP with people who find it difficult or impossible to communicate verbally, documentation of wishes and preferences, including information transfer, end-of-life decision-making, and preconditions for optimal implementation of ACP. Almost all recommendations received a grading representing low to very low-quality evidence.

Conclusion

No high-quality guidelines are available for ACP in dementia care. By combining evidence with expert and user opinions, we have defined a unique set of recommendations for ACP in people living with dementia. These recommendations form a valuable tool for educating healthcare professionals on how to perform ACP across settings.

Knowledge of, and participation in, advance care planning: A cross-sectional study of acute and critical care nurses' perceptions

BACKGROUND

Nurses have a core role in facilitating discussions and enacting decisions about end-of-life issues for patients in hospitals. Nurses' own knowledge and attitudes may influence whether they engage in meaningful end-of-life conversations with patients.

AIMS

To determine in a sample of nurses working in acute and critical care hospital wards: 1) their knowledge of advance care planning, including the authority of substitute decision-makers and legal validity of advance directives; 2) their own participation in advance care planning decision-making practices; and 3) associations between nurses' socio-demographic characteristics; clinical expertise; and knowledge and behaviour in relation to advance care planning practices.

DESIGN

Questionnaire-based, cross-sectional study.

SETTING AND PARTICIPANTS

The study was conducted with 181 registered and enrolled nurses employed in acute and critical care wards of three metropolitan hospitals in Australia.

RESULTS

Nurses were least knowledgeable about items relating to the authority of medical (56%) and financial (42%) substitute decision-makers. Few nurses had prepared advance directives (10%) or appointed medical (23%) or financial (27%) decision-makers, when compared to discussing end-of-life wishes (53%) or organ donation (75%). Overall, 15% of nurses had not engaged in any advance care planning practices. Nurses who had cared for 11-30 dying patients in the last six months were more likely to have an increased knowledge score. Older nurses were more likely to participate in a greater number of advance care planning practices and an increase in shifts worked per week led to a significant decrease in nurses' participation.

CONCLUSION

Nurses have a key role in providing advice and engaging dying patients and their families in advance care planning practices. Nurses' own knowledge and rates of participation are low. Further education and support is needed to ensure that nurses have an accurate knowledge of advance care planning practices, including how, when and with whom wishes should be discussed and can be enacted.

Increasing advance personal planning: the need for action at the community level

BACKGROUND

Advance personal planning is the process by which people consider, document and communicate their preferences for personal, financial and health matters in case they lose the ability to make decisions or express their wishes in the future.

DISCUSSION

Advance personal planning is most often undertaken by individuals who are seriously ill, often in the context of a medical crisis and/or at the time of admission to hospital. However, the clinical utility and legal validity of the planning process may be compromised in these circumstances. Patients may lack sufficient capacity to meaningfully engage in advance personal planning; there may be insufficient time to adequately reflect on and discuss wishes with key others; and there may also be limited opportunity for inter-professional input and collaboration in the process. Here, we propose an agenda for research to advance the science of advance personal planning by promoting a 'whole community' approach. Adoption of advance personal planning at a community level may be achieved using a variety of strategies including public media campaigns, intervening with professionals across a range of health care and legal settings, and mobilising support from influential groups and local government. One potentially promising method for encouraging earlier adoption of advance personal planning among a broader population involves a community action approach, whereby multiple evidence-based strategies are integrated across multiple access points. Community action involves calling on community members, professionals, community and/or government organisations to work collaboratively to design and systematically implement intervention strategies with the aim of bringing about desired behaviour change. An example of a community action trial to improving uptake and quality of advance personal planning is described.

CONCLUSION

While promising, there is a need for rigorous evidence to demonstrate whether a community action approach is effective in establishing whole community adoption of advance personal planning.

Perceived barriers and facilitators to goals of care discussions in the emergency department: A descriptive analysis of the views of emergency medicine physicians and residents

Objective

Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.

Methods

A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.

Results

Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).

Conclusions

Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.