Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

IMPORTANCE

There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

OBJECTIVE

To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

PROCESS

Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

EVIDENCE SYNTHESIS

Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

RECOMMENDATIONS

Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

CONCLUSIONS AND RELEVANCE

This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

Estimating survival in advanced cancer: a comparison of estimates made by oncologists and patients

PURPOSE

To compare estimates of expected survival time (EST) made by patients with advanced cancer and their oncologists.

METHODS

At enrolment patients recorded their "understanding of how long you may have to live" in best-case, most-likely, and worst-case scenarios. Oncologists estimated survival time for each of their patients as the "median survival of a group of identical patients". We hypothesized that oncologists' estimates of EST would be unbiased (~ 50% longer or shorter than the observed survival time [OST]), imprecise (< 33% within 0.67 to 1.33 times OST), associated with OST, and more accurate than patients' estimates of their own survival.

RESULTS

Twenty-six oncologists estimated EST for 179 patients. The median estimate of EST was 6.0 months, and the median OST was 6.2 months. Oncologists' estimates were unbiased (56% longer than OST), imprecise (27% within 0.67 to 1.33 times OST), and significantly associated with OST (HR 0.88, 95% CI 0.82 to 0.93, p < 0.01). Only 41 patients (23%) provided a numerical estimate of their survival with 107 patients (60%) responding "I don't know". The median estimate by patients for their most-likely scenario was 12 months. Patient estimates of their most-likely scenario were less precise (17% within 0.67 to 1.33 times OST) and more likely to overestimate survival (85% longer than OST) than oncologist estimates.

CONCLUSION

Oncologists' estimates were unbiased and significantly associated with survival. Most patients with advanced cancer did not know their EST or overestimated their survival time compared to their oncologist, highlighting the need for improved prognosis communication training. Trial registration ACTRN1261300128871.

Attitudes and self-reported end-of-life care of Australian and New Zealand intensive care doctors in the context of organ donation after circulatory death

The incidence of organ donation after circulatory death (DCD) in Australia and New Zealand (ANZ) has steadily increased in recent years. Intensive care doctors are vital to the implementation of DCD and healthcare professionals' attitudes to DCD can influence their participation. In order to determine ANZ intensive care doctors' attitudes to DCD, to explore if demographic characteristics influence attitude to DCD and to assess if attitude to DCD can predict palliative prescription rationale at the end of life of DCD donors, a cross-sectional online survey was distributed to ANZ intensive care doctors and responses collected between 29 April and 10 June 2016. Exploratory factor analysis was used to define various attributes of attitude to DCD. Results were subjected to comparative statistical analyses to examine the relation between demographic data and attitude to DCD. Multiple regression models were used to examine if attitude to DCD could predict intensive care doctors' palliative prescription rationales at the end of life of DCD donors. One hundred and sixty-one intensive care doctors responded to the survey with 69.4% having worked in intensive care for ten years or more. Respondents responded positively to the support of and perceived importance of DCD in helping those who would benefit from the donations (constructive attributes)(mean composite factor score = 3.84, standard deviation [SD] 0.83), they positively perceived that conducive and facilitative orchestration of DCD helps families cope (mean composite factor score = 3.94, SD 0.72) and that they would manage a DCD donor similar to any patient at the end of their life (mean score = 3.94, SD 0.72). Respondents responded negatively to having concerns that the circulatory death of potential DCD donors does not occur within the specified time frame (mean score = 2.28, SD 1.02). There was an association between organ donation professional education courses, familiarity with national guidelines and positive attitudes to certain attributes of attitude to DCD. Regression models demonstrated the attitude to DCD may predict intensive care doctors' palliative medication prescription rationales at the end of life of the DCD donor. Intensive care doctors in ANZ adopt a morally neutral attitude to DCD where they recognise the importance of organ donation, and support and conduct DCD as a part of good end-of-life care.

Platelet Loss across the Hemofilter during Continuous Hemofiltration

BACKGROUND

Thrombocytopenia is a common finding in patients in the intensive care unit receiving continuous renal replacement therapy (CRRT). It is unknown if the hemofilter itself contributes to the platelet loss.

OBJECTIVE

To measure the direct effect of the hemofilter on platelet counts during CRRT.

DESIGN

Prospective, observational study.

SETTING

Intensive care unit of a University hospital.

PATIENTS

Critically ill patients with acute renal failure receiving CRRT.

METHODS

Two samples of blood were drawn simultaneously, pre-filter and post-filter, and analyzed for platelet count. A correction factor was applied to the post-filter platelet count to adjust for the hemoconcentrating effect of net ultrafiltration.

RESULTS

Forty-eight sets of paired data from 22 patients were studied. There was a small but significant decrease in mean platelet count across the hemofilter. The mean platelet count drop was 2.32 x 10(9)/L (s.e. 1.06, p = 0.0487, 95% CI (0.01, 4.62)). Blood flow was strongly related to degree of platelet loss, with a decreased loss of 0.07 x 10(9)/L for every ml/min increase in blood flow (p = 0.015). There was no overall decrease in concurrently measured red cell counts across the hemofilter. However, there was a machine-specific affect on red cell loss (p < 0.0001). The total calculated daily platelet loss across the filter was 625 x 10(9) cells.

CONCLUSION

The hemofilter may contribute to the thrombocytopenia seen during CRRT, by means of either destruction or retention of platelets during passage. This affect appears attenuated by higher blood flows. This information is useful in the assessment of a low platelet count in patients receiving CRRT.

An Interview Study of Patient and Caregiver Perspectives on Advance Care Planning in ESRD

BACKGROUND

Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, it can be an emotionally charged process for patients with kidney disease and their caregivers. This study aimed to describe the perspectives and attitudes of patients with end-stage renal disease (ESRD) and their caregivers toward ACP.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

Patients with ESRD (n=24) and their caregivers (n=15) aged 36 to 91 years at various stages of ACP ("not commenced," "in progress," or "completed") from 3 renal services.

METHODOLOGY

Semistructured interviews.

ANALYTICAL APPROACH

Transcripts were analyzed using thematic analysis.

RESULTS

5 major themes were identified: articulating core values (avoiding futile and undignified treatment, reevaluating terms of dialysis, framing a life worth living, and refusing to be a burden), confronting conversations (signifying death and defeat, accepting inevitable death, and alleviating existential tension), negotiating mutual understanding (broaching taboos and assisting conflicted caregivers), challenging patient autonomy (family pressures to continue dialysis, grief diminishing caregivers' capacity, and leveraging support), and decisional disempowerment (lacking medical transparency and disappointment with clinical disinterest).

LIMITATIONS

Only English-speaking patients/caregivers participated in the interview.

CONCLUSIONS

ACP provides patients with ESRD and their caregivers a conduit for accepting and planning for impending death and to express treatment preferences based on self-dignity and value of living. However, ACP can be considered taboo, may require caregivers to overcome personal and decisional conflict, and may be complex if patients and caregivers are unable to accept the reality of the patient's illness. We suggest that ACP facilitators and clinicians make ACP more acceptable and less confrontational to patients and caregivers and that strategies be put in place to support caregivers who may be experiencing overwhelming grief or who have conflicting goals, particularly when they are called on to make end-of-life decisions.

Clinicians' Perspectives on Advance Care Planning for Patients With CKD in Australia: An Interview Study

BACKGROUND

Advance care planning (ACP) empowers patients to consider and communicate their current and future treatment goals. However, ACP is not widely implemented in chronic kidney disease (CKD) care settings. This study aims to describe clinicians' beliefs, challenges, and perspectives of ACP in patients with CKD.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

Nephrologists (n=20), nurses (n=7), and social workers (n=4) with a range of experience in facilitating ACP for patients with CKD across Australia.

METHODOLOGY

Semistructured interviews were digitally recorded and transcribed verbatim.

ANALYTICAL APPROACH

Transcripts were analyzed using thematic analysis.

RESULTS

5 major themes were identified: facilitating informed decision making (avoiding preconceptions, conveying complete truths, focusing on supportive care, and synchronizing with evolving priorities), negotiating moral boundaries (contending with medical futility and respecting patient vs family autonomy), navigating vulnerable conversations (jeopardizing the therapeutic relationship, compromising professional confidence, emotionally invested, and enriching experiences), professional disempowerment (unsupportive culture, doubting logistical feasibility, and making uncertain judgments), and clarifying responsibilities (governing facilitation, managing tensions, and transforming multidisciplinary relationships).

LIMITATIONS

Some findings may be specific to the Australian context.

CONCLUSIONS

The tensions among themes reflect that ACP is paradoxically rewarding for clinicians because ACP empowers patients yet can expose personal and professional vulnerabilities. Clinicians believe that a more collaborative approach is needed, with increased efforts to identify the evolving and individualized needs and goals of patients with CKD. Models of ACP that address clinicians' personal and professional vulnerabilities when initiating ACP may foster greater confidence and cultural acceptance of ACP in the CKD setting.

Advance care planning in patients with incurable cancer: study protocol for a randomised controlled trial

INTRODUCTION

There is limited evidence documenting the effectiveness of Advance Care Planning (ACP) in cancer care. The present randomised trial is designed to evaluate whether the administration of formal ACP improves compliance with patients' end-of-life (EOL) wishes and patient and family satisfaction with care.

METHODS AND ANALYSIS

A randomised control trial in eight oncology centres across New South Wales and Victoria, Australia, is designed to assess the efficacy of a formal ACP intervention for patients with cancer. Patients with incurable cancer and an expected survival of 3-12 months, plus a nominated family member or friend will be randomised to receive either standard care or standard care plus a formal ACP intervention. The project sample size is 210 patient-family/friend dyads. The primary outcome measure is family/friend-reported: (1) discussion with the patient about their EOL wishes and (2) perception that the patient's EOL wishes were met. Secondary outcome measures include: documentation of and compliance with patient preferences for medical intervention at the EOL; the family/friend's perception of the quality of the patient's EOL care; the impact of death on surviving family; patient-family and patient-healthcare provider communication about EOL care; patient and family/friend satisfaction with care; quality of life of patient and family/friend subsequent to trial entry, the patient's strength of preferences for quality of life and length of life; the costs of care subsequent to trial entry and place of death.

ETHICS AND DISSEMINATION

Ethical approval was received from the Sydney Local Health District (RPA Zone) Human Research Ethical Committee, Australia (Protocol number X13-0064). Study results will be submitted for publication in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

Pre-results; ACTRN12613001288718.

Organ donation after circulatory death in a university teaching hospital

Although organ transplantation is well established for end-stage organ failure, many patients die on waiting lists due to insufficient donor numbers. Recently, there has been renewed interest in donation after circulatory death (DCD). In a retrospective observational study we reviewed the screening of patients considered for DCD between March 2007 and December 2012 in our hospital. Overall, 148 patients were screened, 17 of whom were transferred from other hospitals. Ninety-three patients were excluded (53 immediately and 40 after review by donation staff). The 55 DCD patients were younger than those excluded (P=0.007) and they died from hypoxic brain injury (43.6%), intraparenchymal haemorrhage (21.8%) and subarachnoid haemorrhage (14.5%). Antemortem heparin administration and bronchoscopy occurred in 50/53 (94.3%) and 22/55 (40%) of cases, respectively. Forty-eight patients died within 90 minutes and proceeded to donation surgery. Associations with not dying in 90 minutes included spontaneous ventilation mode (P=0.022), absence of noradrenaline infusion (P=0.051) and higher PaO2:FiO2 ratio (P=0.052). The number of brain dead donors did not decrease over the study period. The time interval between admission and death was longer for DCD than for the 45 brain dead donors (5 [3-11] versus 2 [2-3] days; P<0.001), and 95 additional patients received organ transplants due to DCD. Introducing a DCD program can increase potential organ donors without reducing brain dead donors. Antemortem investigations appear to be acceptable to relatives when included in the consent process.

Australian Psychiatrists' Support for Psychiatric Advance Directives: Responses to a Hypothetical Vignette

This study examines whether Australian psychiatrists would support requests in a psychiatric advance directive (PAD) and the reasons underlying their decisions in response to a hypothetical vignette. An online survey was completed by 143 psychiatrists. Fewer than 3 out of 10 psychiatrists supported the patient to create a PAD which requested cessation of pharmacotherapy (27%) or remaining out of hospital and not being subject to an involuntary treatment order (24%) should their depression condition deteriorate. A thematic analysis showed that patient autonomy was the strongest theme among those who supported the patient to create a PAD, whereas the clinical profile of and risk to the patient and the professional or ethical imperative of the psychiatrist were strongest among those who were unsure about supporting the patient or who did not support the patient. These findings provide a challenge about how to fulfil obligations under the United Nations Convention on the Rights of Persons with Disabilities (2006).

Advance care planning in Australia: what does the law say?

Advance care planning (ACP) assists people to plan for their future health and personal care. ACP encourages a person to legally appoint a substitute decision maker (SDM) and to document any specific wishes regarding their future health care in an advance care directive (ACD). Formal documentation of wishes increases the chances that a person’s wishes will be known and followed. However, one of the biggest impediments for doctors following the person’s wishes is uncertainty surrounding the law, which is complicated and varies between the states and territories of Australia. SDM legislation varies regarding who can be appointed, how they are appointed, the powers that an SDM can be given and the decision-making principles that the SDM needs to follow. In circumstances where an SDM has not been appointed, the hierarchy for determining the default SDM for a person also varies between states. Although many states have legislated ACD forms allowing for documentation of a person’s health care wishes, these forms allow for different things to be documented and have different requirements to be valid. The Australian population is mobile, with patients frequently moving between states. The status of ACP documentation created in a state other than the state in which a patient requires treatment also varies, with some states recognising interstate ACDs whereas others do not. This article outlines the legal status of ACDs, within Australian jurisdictions, including the legal validity of interstate ACDs, and argues that uniform laws and documents would assist with awareness and understanding of, and compliance with, ACDs.

Feasibility and acceptability of advance care planning in elderly Italian and Greek speaking patients as compared to English-speaking patients: an Australian cross-sectional study

OBJECTIVES

To assess the feasibility and acceptability of facilitated advance care planning (ACP) discussions in elderly Italian and Greek-speaking inpatients compared to English-speaking inpatients.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study with convenience sampling was conducted in Melbourne, Australia, and recruited hospital inpatients with medical decision-making capacity, aged 65 years or above, who spoke Greek (25 patients), Italian (24 patients) or English (63 patients).

INTERVENTION

Facilitated ACP was offered, aiming to assists patients to consider and discuss their goals, values, beliefs and future treatment wishes with their family and doctor; to help them consider how they would like healthcare decisions made in the future if they become unable to do this for themselves; and to complete advance care directives.

MAIN OUTCOME MEASURES

The completion of ACP discussions, their duration, advance care directive completion and utilisation of interpreters.

RESULTS

Of 112 patients, 109 (97%) had at least one discussion, 63 (54%) completed advance care directives, either nominating a substitute decision-maker, documenting their wishes or both, and 76 (68%) included family in discussions. The median duration of discussions for all patients was slightly more than 1 h, over two visits. There were no differences between the Greek-speaking and the Italian-speaking patients, or between the Non-English speaking and the English-speaking patients in any of these measures. Only 14 non-English speaking patients, (30%) utilised interpreters, but when utilised, patients were much more likely (p<0.005) to complete advance care directives.

CONCLUSIONS

Facilitated ACP in elderly Italian and Greek-speaking patients is feasible, acceptable and is similar to that for English-speaking patients.

Advance care planning in palliative care: a national survey of health professionals and service managers

OBJECTIVE

To identify the attitudes, knowledge and practices regarding advance care planning (ACP) in palliative care.

METHODS

A nationwide online survey was distributed to Australian palliative care services associated with the Palliative Care Outcomes Collaboration (n=105). Seventy-three health professionals (HPs) and 59 service managers completed the survey.

RESULTS

Regarding ACP, 51% of service managers reported relevant policies and procedures were in place in their service and 44% included ACP in job descriptions. Most HPs were confident in undertaking ACP, including initiating discussions with patients and complying with documents; however, only 44% reported receiving ACP specific training. Although 58% of HPs reported having conversations about ACP with more than 11 patients in the past 6 months, only 44% of managers report that it is offered to most patients. Thirty per cent of HPs were aware of others not adhering to patient wishes in the past 6 months and only 43% of HPs (and 37% of managers) believed ACP is done well within their service.

CONCLUSIONS

This first national survey examining ACP in palliative care services demonstrates there is a need to improve systems to support ACP and to understand circumstances in which ACP wishes are not followed.

Current advance care planning practice in the Australian community: an online survey of home care package case managers and service managers

BACKGROUND

Advance care planning (ACP) is the process of planning for future healthcare that is facilitated by a trained healthcare professional, whereby a person's values, beliefs and treatment preferences are made known to guide clinical decision-making at a future time when they cannot communicate their decisions. Despite the potential benefits of ACP for community aged care clients the availability of ACP is unknown, but likely to be low. In Australia many of these clients receive services through Home Care Package (HCP) programs. This study aimed to explore current attitudes, knowledge and practice of advance care planning among HCP service managers and case managers.

METHODS

An invitation to take part in a cross-sectional online survey was distributed by email to all HCP services across Australia in November 2012. Descriptive analyses were used to examine overall patterns of responses to each survey item in the full sample.

RESULTS

120 (response rate 25%) service managers and 178 (response rate 18%) case managers completed the survey. Only 34% of services had written ACP policies and procedures in place and 48% of case managers had previously completed any ACP training. In addition, although most case managers (70%) had initiated an ACP discussion in the past 12 months and viewed ACP as part of their role, the majority of the conversations (80%) did not result in documentation of the client's wishes and most (85%) of the case managers who responded did not believe ACP was done well within their service.

CONCLUSIONS

This survey shows low organisational ACP systems and support for case managers and a lack of a normative approach to ACP across Australian HCP services. As HCPs become more prevalent it is essential that a model of ACP is developed and evaluated in this setting, so that clients have the opportunity to discuss and document their future healthcare wishes if they choose to.

Palliative care health professionals’ experiences of caring for patients with advance care directives

Objective To explore the health professionals’ (HPs) perceptions and experiences of advance care directives (ACDs) and advance care planning in Australian palliative care services. Methods A nationwide survey of 105 palliative care services was conducted, with two HPs from each service invited to participate. A qualitative analysis of open responses about advance care planning was undertaken. Results Sixty questionnaires were returned with open responses. Most responders were nurses (75%), aged ≥40 years (80%) and with a mean of 12 years palliative care experience. Data were grouped into four key themes: (1) the ACD; (2) the process of developing ACDs; (3) the process of using ACDs; and (4) the consequences of having ACDs. Participants were positive about advance care planning, commenting that ongoing communication about end-of-life care ensures mutual understanding between patients, family and HPs. Provision of care was considered easier and more efficient with an ACD in place. ACDs were perceived to reduce distrust and conflict between family, friends and HPs, and promote communication. Suboptimal documentation, clarity and explicitness limited the usefulness of ACDs when they were available. Conclusions Advance care planning benefits HPs, patients and their family. To maximise these benefits, ACDs need to be clear, comprehensive, medically relevant and transportable documents. What is known about the topic? Ideally, advance care planning encompasses the identification and documentation of a person’s preferences for future medical treatments and care in preparation for an occasion when the person cannot express their values and wishes. The uptake and practice of advance care planning is inconsistent, and the extent to which it is used by health professionals and patients is variable. Many people are cared for at the end of life in specialist palliative care services, but the intersection between palliative care and advance care planning remains under-researched. What does this paper adds? ACDs facilitate communication and advance care planning; help establish trust between health professionals, patients and their families; and make multiple aspects of care easier for HPs. Processes surrounding ACDs, particularly inadequate documentation, limit adherence and application. What are the implications for practitioners? Clear communication is necessary for effective ACD development and application. The presence of an ACD makes communication and advance care planning easier, and improves trust between HPs, patients and their family. To be useful, ACDs must be clear, comprehensive, medically relevant, transportable documents.

Development and evaluation of an aged care specific Advance Care Plan

Objectives

To report on the quality of advance care planning (ACP) documents in use in residential aged care facilities (RACF) in areas of Victoria Australia prior to a systematic intervention; to report on the development and performance of an aged care specific Advance Care Plan template used during the intervention.

Design

An audit of the quality of pre-existing documentation used to record resident treatment preferences and end-of-life wishes at participating RACFs; development and pilot of an aged care specific Advance Care Plan template; an audit of the completeness and quality of Advance Care Plans completed on the new template during a systematic ACP intervention.

Participants and setting

19 selected RACFs (managed by 12 aged care organisations) in metropolitan and regional areas of Victoria.

Results

Documentation in use at facilities prior to the ACP intervention most commonly recorded preferences regarding hospital transfer, life prolonging treatment and personal/cultural/religious wishes. However, 7 of 12 document sets failed to adequately and clearly specify the resident's preferences as regards life prolonging medical treatment. The newly developed aged care specific Advance Care Plan template was met with approval by participating RACFs. Of 203 Advance Care Plans completed on the template throughout the project period, 49% included the appointment of a Medical Enduring Power of Attorney. Requests concerning medical treatment were specified in almost all completed documents (97%), with 73% nominating the option of refusal of life-prolonging treatment. Over 90% of plans included information concerning residents’ values and beliefs, and future health situations that the resident would find to be unacceptable were specified in 78% of completed plans.

Conclusions

Standardised procedures and documentation are needed to improve the quality of processes, documents and outcomes of ACP in the residential aged care sector.

Quality of advance care planning policy and practice in residential aged care facilities in Australia

OBJECTIVES

To assess existing advance care planning (ACP) practices in residential aged care facilities (RACFs) in Victoria, Australia before a systematic intervention; to assess RACF staff experience, understanding of and attitudes towards ACP.

DESIGN

Surveys of participating organisations concerning ACP-related policies and procedures, review of existing ACP-related documentation, and pre-intervention survey of RACF staff covering their role, experiences and attitudes towards ACP-related procedures.

SETTING

19 selected RACFs in Victoria.

PARTICIPANTS

12 aged care organisations (representing 19 RACFs) who provided existing ACP-related documentation for review, 12 RACFs who completed an organisational survey and 45 staff (from 19 RACFs) who completed a pre-intervention survey of knowledge, attitudes and behaviour.

RESULTS

Findings suggested that some ACP-related practices were already occurring in RACFs; however, these activities were inconsistent and variable in quality. Six of the 12 responding RACFs had written policies and procedures for ACP; however, none of the ACP-related documents submitted covered all information required to meet ACP best practice. Surveyed staff had limited experience of ACP, and discrepancies between self reported comfort, and levels of knowledge and confidence to undertake ACP-related activities, indicated a need for training and ongoing organisational support.

CONCLUSIONS

Surveyed organisations â policies and procedures related to ACP were limited and the quality of existing documentation was poor. RACF staff had relatively limited experience in developing advance care plans with facility residents, although attitudes were positive. A systematic approach to the implementation of ACP in residential aged care settings is required to ensure best practice is implemented and sustained.