Assessing Advance Care Planning Fidelity within the Context of Cognitive Impairment: The SHARE Trial

Advance care planning in adults ages 80 years and older with impaired cognition: Using actual conversations to examine best practices

INTRODUCTION

Recommendations for advance care planning (ACP) in persons with cognitive impairment are based on expert input without insight from actual ACP conversations.

METHODS

We used thematic analysis to analyze transcripts of ACP conversations for 88 older adults with normal cognition (n = 15), mild cognitive impairment (n = 13), and scores consistent with dementia (n = 60).

RESULTS

Patients with dementia were least verbally active; however, some shared values and identified surrogates. We identified three themes: (1) cognitive impairment inhibits participation in ACP, but individuals with dementia are able to contribute; (2) care partners have a key role in supporting ACP across the spectrum of cognitive impairment; and (3) structured questions about values and tailored communication strategies can facilitate engagement of older adults with dementia.

DISCUSSION

Our findings reinforce best practice recommendations for early ACP and identify strategies to increase patient engagement among older adults with cognitive impairment with support of care partners.

HIGHLIGHTS

Data from actual ACP conversations involving older adults with a range of cognitive function and their care partners reinforce best practice recommendations and suggest practical implications for education and training. Family involvement in ACP was valued by older adults and improved engagement. ACP initiatives should prioritize eliciting values of older adults with dementia and improving skills for communication to increase engagement.

Sharing health care wishes among older adults with cognitive impairment in primary care: Results from a randomized controlled trial

INTRODUCTION

Best practices for conducting advance care planning (ACP) among persons with cognitive impairment exist, but evidence-based models are lacking for the primary care setting.

METHODS

We tested a remote multicomponent ACP model (SHARE) versus minimally enhanced usual care in 273 person-family dyads from eight primary care practices.

RESULTS

Mean patient age was 88.0 years, 85 (31.1%) were Black/Latino; 189 (69.2%) had moderate-to-severe cognitive impairment. Most (101/145; 69.6%) intervention dyads engaged in ACP. At follow-up, no treatment effect was observed for care partner-reported quality of communication about end-of-life care at 6 or 12 months, but intervention patients reported better quality of communication about end-of-life care at 12 months. Intervention care partners and patients reported greater readiness to engage in ACP at 6 and 12 months, respectively, and increased completion of key aspects of ACP.

DISCUSSION

SHARE supported key aspects of ACP processes and communication about end-of-life care.

HIGHLIGHTS

Primary care-based models of ACP for persons with dementia are lacking. Involving persons with cognitive impairment in remote ACP is feasible with care partner involvement. Results indicate benefit for aspects of ACP processes and communication about end-of-life care.

Feasibility of Using Simulation to Evaluate Implementation Fidelity in an Advance Care Planning Pragmatic Trial

Background and Objectives: Traditional methods of fidelity monitoring are not possible in pragmatic trials in real-world clinical settings. We describe our approach to monitoring and reinforcing the fidelity to ACP conversations for a hard-to-reach subpopulation by using standardized patients in a pragmatic trial. Research Design and Methods: We developed standardized patient scenarios grounded in the Respecting Choices First Steps™ Advance Care Planning curriculum to provide an opportunity to reinforce and assess ACP facilitator competency. Scenarios represented one-on-one encounters. The first case was a standardized patient with cognitive impairment and the second case involved a standardized patient with dementia and their care partner. A previously validated fidelity checklist was used to score skills and behaviors observed during simulations including encounter set-up, ACP topics, and general communication. Simulations involved voice teleconferencing to align primary modality of ACP in the pragmatic trial. Results: Six facilitators completed two standardized patient cases each. Overall fidelity scores were moderately high (78.8% ± 11.7; 63.4 - 95.6) for the case with cognitive impairment and for the case with the patient with dementia and care partner (76.2% ± 13.0; 54.4 - 91.5). Discussion and Implications: Simulation using standardized patients supported fidelity monitoring and provided coachable feedback to support facilitator competency. Our study can help inform future research and training related to advance care planning in older adults living with Alzheimer's disease and related disorders.