Comparison of Web-Based and Paper Advance Directives: A Pilot Randomized Clinical Trial

The comprehensiveness and comprehensibility of publicly-available, state-approved advance directive documents

The COVID-19 pandemic has increased attention to end-of-life decision-making and advance care planning. Advance directives (ADs) are documents that express an individual's wishes regarding their medical care if they are incapacitated and may appoint someone to make decisions for them. The purpose of the current study was to evaluate the comprehensiveness and comprehensibility of the widely available state-approved AD documents provided to the public online. Their content was coded using a grounded theory approach, and the reading level of the documents was assessed. Preferences related to important issues, such as pain relief, were commonly included (92.2% of forms), but other issues, such as whether someone would approve of artificial respiration (39.2%) or CPR (35.3%), were less often addressed. The average reading level of the forms (M = grade 7.64; SD = 1.28) was above the recommended 5th grade level. Overall, there was meaningful variability in the comprehensiveness and comprehensibility of AD documents, suggesting incompatibility for those recording their end-of-life preferences across states and the need for future work to increase their user-friendliness and ability to record authentic advance care wishes.

What is the evidence for efficacy of advance care planning in improving patient outcomes? A systematic review of randomised controlled trials

Objectives

To conduct an up-to-date systematic review of all randomised controlled trials assessing efficacy of advance care planning (ACP) in improving patient outcomes, healthcare use/costs and documentation.

Design

Narrative synthesis conducted for randomised controlled trials. We searched electronic databases (MEDLINE/PubMed, Embase and Cochrane databases) for English-language randomised or cluster randomised controlled trials on 11 May 2020 and updated it on 12 May 2021 using the same search strategy. Two reviewers independently extracted data and assessed methodological quality. Disagreements were resolved by consensus or a third reviewer.

Results

We reviewed 132 eligible trials published between 1992 and May 2021; 64% were high-quality. We categorised study outcomes as patient (distal and proximal), healthcare use and process outcomes. There was mixed evidence that ACP interventions improved distal patient outcomes including end-of-life care consistent with preferences (25%; 3/12 with improvement), quality of life (0/14 studies), mental health (21%; 4/19) and home deaths (25%; 1/4), or that it reduced healthcare use/costs (18%; 4/22 studies). However, we found more consistent evidence that ACP interventions improve proximal patient outcomes including quality of patient–physician communication (68%; 13/19), preference for comfort care (70%; 16/23), decisional conflict (64%; 9/14) and patient-caregiver congruence in preference (82%; 18/22) and that it improved ACP documentation (a process outcome; 63%; 34/54).

Conclusion

This review provides the most comprehensive evidence to date regarding the efficacy of ACP on key patient outcomes and healthcare use/costs. Findings suggest a need to rethink the main purpose and outcomes of ACP.

PROSPERO registration number

CRD42020184080.

Feasibility and acceptability of a web-based advance care plan for dementia

While advance care planning (ACP) can help elicit preferences and is associated with improved end-of-life outcomes, persons living with dementia (PLWD) in nursing homes are rarely included in ACP. Web-based decision aids are a readily available tool to engage PLWD in ACP, but none are designed for the unique needs of PLWD, particularly those residing in nursing homes. Our Memory Care Wishes (OMCW) was adapted from a publicly available web-based ACP tool in collaboration with dementia care experts. This study aimed to explore the acceptability of OMCW. We used a convergent, mixed methods design to describe PLWD and surrogates' experiences using the OMCW website. Participants described ease of use, comfort with viewing, helpfulness for planning, and likelihood to recommend. Overall, OMCW is acceptable, however, PLWD continue to have difficulties understanding and engaging with some website content. Modifications were incorporated based on these findings, setting the stage for implementation and effectiveness testing.