A review of the implementation and research strategies of advance care planning in nursing homes

Abstract

BackgroundNursing home (NH) patients have complex health problems, disabilities and needs for Advance Care Planning (ACP). The implementation of ACP in NHs is a neglected research topic, yet it may optimize the intervention efficacy, or provide explanations for low efficacy. This scoping review investigates methods, design and outcomes and the implementation of ACP (i.e., themes and guiding questions, setting, facilitators, implementers, and promoters/barriers).MethodsA systematic search using ACP MESH terms and keywords was conducted in CINAHL, Medline, PsychINFO, Embase and Cochrane libraries. We excluded studies on home-dwelling and hospital patients, including only specific diagnoses and/or chart-based interventions without conversations.ResultsSixteen papers were included. There were large variations in definitions and content of ACP, study design, implementation strategies and outcomes. Often, the ACP intervention or implementation processes were not described in detail. Few studies included patients lacking decision-making capacity, despite the fact that this group is significantly present in most NHs. The chief ACP implementation strategy was education of staff. Among others, ACP improved documentation of and adherence to preferences. Important implementation barriers were non-attending NH physicians, legal challenges and reluctance to participate among personnel and relatives.ConclusionACP intervention studies in NHs are few and heterogeneous. Variation in ACP definitions may be related to cultural and legal differences. This variation, along with sparse information about procedures, makes it difficult to collate and compare research results. Essential implementation considerations relate to the involvement and education of nurses, physicians and leaders.

“I just think that we should be informed” a qualitative study of family involvement in advance care planning in nursing homes

“…The larger research project consists of three parts, with different methods and perspectives. Part one is a literature review on implementation and research strategies of ACP in nursing homes [38]. In part two we study if and how ACP is used in Norwegian nursing homes and this part consists of A) a survey to investigate practice and prevalence of ACP in Norwegian nursing homes and B) a qualitative study of ongoing advance care planning practices in nursing homes.…”

Patient safety culture in Norwegian nursing homes

“…Meanwhile, almost one half of the Norwegian population dies in a nursing home, so that end-of-life care and advance care planning addressing the approaching death, and the practical challenges regarding ethics, treatment and care, should be initiated well before the patient reaches a critical state [23]. …”

An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting

“…Important stakeholders, including nursing home staff and physicians, are not “gatekeeping,” or preventing OPTIMISTIC RNs from engaging in ACP with residents. Furthermore, when given the opportunity to participate in ACP, only a small minority of residents and families refused, in contrast to suggestions that this is a common barrier . OPTIMISTIC RNs did not report barriers found to be common in other research such as family disagreements .…”

“…There are few published descriptions of ACP implementation in the long‐term care setting, and therefore minimal information is available about what is required to integrate ACP successfully into practice . The OPTIMISTIC experience suggests that ACP implementation in this setting requires a significant investment of resources, including dedicated staff, training, and support.…”

“…To identify models of care to address these concerns, CMS funded seven 4‐year‐long demonstration projects, including one based at Indiana University. The multicomponent Indiana Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project draws in part from evidence suggesting that ACP and POLST have the potential to reduce unnecessary and burdensome hospitalizations of nursing home residents, but the literature contains few descriptions of ACP and POLST implementation …”