Experiences with and outcomes of Advance Care Planning in bereaved relatives of frail older patients: a mixed methods study

Effectiveness of interventions for informal caregivers of community-dwelling frail older adults: A systematic review and meta-analysis

AIM

Systematic reviews on interventions for informal caregivers of community-dwelling frail older adults were published over a decade ago and they mistook frailty for other severe age-related conditions like disability and dementia. Therefore, this study aimed to systematically synthesize these interventions supporting these caregivers identified by an acknowledged frailty assessment instrument and to examine their effectiveness on caregiver-related outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Fourteen electronic databases, grey literature and reference lists were systematically searched for randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) from inception to November 3, 2023.

METHODS

Methodology quality and risk of bias were assessed. Data were meta-analysed using the Comprehensive Meta-Analysis, version 3.0. Studies and outcomes unsuitable for meta-analysis were summarized by narrative syntheses.

RESULTS

Four studies consisting of three RCTs and one NRCT were included involving 350 participants. Interventions for caregivers of frail older adults included multicomponent interventions (n = 3) and education intervention (n = 1). Interventions had a moderate effect on reducing depression and showed nonsignificant effects on caregiver burden, caregiving time or quality of life (QoL). The PEDro scores for RCTs ranged from 6 to 8, indicating good methodologic quality, but were all judged as high risk of bias. The NRCT reported all methodologic aspects and was at low risk of bias.

CONCLUSIONS

Few studies focus on interventions targeting caregivers of frail older adults, and their effectiveness may vary by outcomes. This review suggested the potential benefits of these interventions in reducing caregivers' depression.

IMPACT

The differential effectiveness by outcomes and high risk of bias of studies implicate that more rigorous studies are warranted.

Hospital care for the dying patient with cancer: does an advance care planning invitation influence bereaved relatives' experiences? A two country survey

OBJECTIVES

Advance care planning (ACP) is not systematically performed in Argentina or Norway. We used the post-bereavement survey of the ERANet-LAC International Care Of the Dying Evaluation (CODE) project (2017-2020) to examine the proportion of relatives who were offered an ACP conversation, the proportion of those not offered it who would have wanted it and whether the outcomes differed between those offered a conversation and those not.

METHODS

Relatives after cancer deaths in hospitals answered the CODE questionnaire 6-8 weeks post bereavement, by post (Norway) or interview (Argentina). Two additional questions asked if the relative and patient had been invited to a conversation about wishes for the patient's remaining lifetime, and, if not invited, whether they would have wanted such a conversation. The data were analysed using mixed-effects ordinal regression models.

RESULTS

276 participants (Argentina 98 and Norway 178) responded (56% spouses, 31% children, 68% women, age 18-80+). Fifty-six per cent had been invited, and they had significantly more positive perceptions about care and support than those not invited. Sixty-eight per cent of the participants not invited would have wanted an invitation, and they had less favourable perceptions about the care, especially concerning emotional and spiritual support.

CONCLUSIONS

Relatives who had been invited to a conversation about wishes for the patient's remaining lifetime had more positive perceptions about patient care and support for the relatives in the patient's final days of life. A majority of the relatives who had not been invited to an ACP conversation would have wanted it.

Advance care planning and caregiver outcomes: intervention efficacy - systematic review

CONTEXT

Caregivers make difficult end-of-life (EOL) decisions for patients, often adversely affecting their own psychological health. Understanding whether advance care planning (ACP) interventions benefit caregivers can enable healthcare systems to use these approaches to better support them.

OBJECTIVE

We conducted a systematic review and meta-analysis to identify and quantify the impacts of ACP interventions on caregiver outcomes.

METHODS

We searched MEDLINE, Embase and Cochrane databases for English-language randomised or cluster randomised controlled trials (RCTs) published until May 2021. Two reviewers independently assessed methodological quality using the Physiotherapy Evidence-Based Database Scale. We conducted a narrative synthesis for each outcome. Difference between arms with a p value of <0.05 was considered statistically significant.

RESULTS

Of the 3487 titles reviewed, 35 RCTs met eligibility; 68.6% were rated high quality. Included RCTs were heterogeneous in intervention characteristics, setting and disease. Meta-analysis of 17 RCTs showed that ACP had large and significant improvement in congruence in EOL care preferences between caregivers and patients (standardised mean difference 0.73, 95% CI 0.42 to 1.05). The effect of ACP on this outcome, however, declined over time. We also found some evidence that ACP improved bereavement outcomes (three of four RCTs), satisfaction with care quality/communication (four of the six RCTs), reduced decisional conflict (two of the two RCTs) and burden (one RCT). No study showed that mental health of caregivers were adversely affected.

CONCLUSION

The review provides most comprehensive evidence about the efficacy of ACP on caregiver outcomes. Findings suggest some evidence of benefit of ACP on caregiver outcomes.

Perspective of geriatric patients on advance care planning in Denmark: a qualitative study

OBJECTIVE

Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations.

DESIGN

Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method.

SETTING

Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark.

PARTICIPANTS

We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview.

RESULTS

This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will.

CONCLUSION

Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Effect of a Video-Assisted Advance Care Planning Intervention on End-of-Life Health Care Transitions Among Long-Stay Nursing Home Residents

OBJECTIVE

To determine the relationship between an advance care planning (ACP) video intervention, Pragmatic Trial of Video Education in Nursing Homes (PROVEN), and end-of-life health care transitions among long-stay nursing home residents with advanced illness.

DESIGN

Pragmatic cluster randomized clinical trial. Five ACP videos were available on tablets or online at intervention facilities. PROVEN champions employed by nursing homes (usually social workers) were directed to offer residents (or their proxies) ≥1 video under certain circumstances. Control facilities employed usual ACP practices.

SETTING AND PARTICIPANTS

PROVEN occurred from February 2016 to May 2019 in 360 nursing homes (119 intervention, 241 control) owned by 2 health care systems. This post hoc study of PROVEN data analyzed long-stay residents ≥65 years who died during the trial who had either advanced dementia or cardiopulmonary disease (advanced illness). We required an observation time ≥90 days before death. The analytic sample included 923 and 1925 advanced illness decedents in intervention and control arms; respectively.

METHODS

Outcomes included the proportion of residents with 1 or more hospital transfer (ie, hospitalization, emergency department use, or observation stay), multiple (≥3) hospital transfers during the last 90 days of life, and late transitions (ie, hospital transfer during the last 3 days or hospice admission on the last day of life).

RESULTS

Hospital transfers in the last 90 days of life among decedents with advanced illness were significantly lower in the intervention vs control arm (proportion difference = -1.7%, 95% CI -3.2%, -0.1%). The proportion of decedents with multiple hospital transfers and late transitions did not differ between the trial arms.

CONCLUSIONS AND IMPLICATIONS

Video-assisted ACP was modestly associated with reduced hospital transfers in the last 90 days of life among nursing home residents with advanced illness. The intervention was not significantly associated with late health care transitions and multiple hospital transfers.

Informal caregivers and advance care planning: systematic review with qualitative meta-synthesis

BACKGROUND

Advance care planning (ACP) is a communication process about a person's values, life goals and preferences for current and future treatment and care. It can improve end-of-life care experiences for care recipients as well as for family caregivers. Knowledge about caregivers' needs might support implementation of ACP interventions suitable to both care recipients and their caregivers.

OBJECTIVE

To explore the experiences and attitudes of informal family caregivers, and their knowledge, regarding ACP.

METHODS

A systematic literature search was conducted (participants: family caregivers; intervention: advance care planning; databases: MEDLINE, PsycINFO, CINAHL, Cochrane Library). Thematic synthesis was applied to qualitative and mixed methods studies; quantitative studies were described in relation to the themes of the meta-synthesis.

RESULTS

57 studies were included, of these 51 in the meta-synthesis. Three themes emerged: (1) caregiver's individual conceptualisation of ACP, (2) caregiver's relationships and (3) ACP process. These themes were incorporated into a longitudinal perspective on the caregiver's ACP trajectory, encompassing the phases (A) life before, (B) ACP process, (C) utilisation of ACP and (D) life after. The implications for ACP activities are described according to each phase.

CONCLUSION

For the benefit of care recipients, healthcare professionals should carefully consider caregivers' conceptualisations of ACP as well as the relationships within the family. They need to be skilled communicators, sensitive to individual needs and equipped with sufficient time resources to tailor ACP interventions to their clients' unique situation. Thus, they will support decision-making according to care recipients' wishes, caregivers' end-of-life experience and their life after bereavement.

PROSPERO REGISTRATION NUMBER

CRD42018082492.

Exploring the Uptake of Advance Care Planning in Older Adults: An Integrative Review

CONTEXT

Advance care planning (ACP) is essential to elicit goals, values, and preferences of care in older adults with serious illness and on trajectories of frailty. An exploration of ACP uptake in older adults may identify barriers and facilitators.

OBJECTIVE

To conduct an integrative review of research on the uptake of ACP in older adults and create a conceptual model of the findings.

METHODS

Using Whittemore and Knafl's methodology, we systematically searched four electronic databases of ACP literature in older adults from 1996 through December 2019. Critical appraisal tools were used to assess study quality, and articles were categorized according to level of evidence. Statistical and thematic analysis was then undertaken.

RESULTS

Among 1081 studies, 78 met inclusion criteria. Statistical analysis evaluated ACP and variables within the domains of demographics, psychosocial, disability and functioning, and miscellaneous. Thematic analysis identified a central category of enhanced communication, followed by categories of 1) provider role and preparation; 2) patient/family relationship patterns; 3) standardized processes and structured approaches; 4) contextual influences; and 5) missed opportunities. A conceptual model depicted categories and relationships.

CONCLUSIONS

Enhanced communication and ACP facilitators improve uptake of ACP. Clinicians should be cognizant of these factors. This review provides a guide for clinicians who are considering implementation strategies to facilitate ACP in real-world settings.

The Impact of Varying Levels of Advance Care Planning Engagement on Perceptions of the End-of-Life Experience Among Caregivers of Deceased Patients With Cancer

CONTEXT

Advance care planning (ACP) is used to prepare patients and caregivers for future "in the moment" decisions at the end-of-life. Patients with cancer generally do not engage in all 3 components of ACP (documented living will, health-care surrogate, end-of-life discussions); however, little is known about the impact of these varying levels of ACP engagement on caregivers postdeath.

OBJECTIVE

To examine the relationship between varying levels of ACP engagement and caregivers' perceptions of cancer decedents' end-of-life experiences.

METHODS

A secondary analysis of the 2002 to 2014 waves of the Health and Retirement Study data using structural equation modeling was conducted. Five levels of ACP engagement were defined: full (discussions/documents), augmented discussions, documents only, discussions only, and no engagement.

RESULTS

Among the 2172 cancer death cases, the analyzed sample included 983 cases where end-of-life decisions occurred. Compared to no ACP, all levels of ACP were significantly associated with caregivers' positive perceptions of cancer decedents' end-of-life experiences (P ≤ .001), controlling for sex, race, and Hispanic ethnicity (R ² = .21). However, the relative impact of each level of ACP engagement was not equal; full engagement (β = .61) was associated with a greater impact compared to each of the partial levels of engagement (augmented discussions [β = .33], documents only [β = .17], discussions only [β = .17]).

CONCLUSION

Partial ACP engagement, not just nonengagement, serves as an important clinically modifiable target to improve the end-of-life care experience among patients with cancer and the perceptions of those experiences among bereaved caregivers.