Advance care planning: A systematic review of randomised controlled trials conducted with older adults

Abstract

Advance care planning (ACP), involving discussions between patients, families and healthcare professionals on future healthcare decisions, in advance of anticipated impairment in decision-making capacity, improves satisfaction and end-of-life care while respecting patient autonomy. It usually results in the creation of a written advanced care directive (ACD). This systematic review examines the impact of ACP on several outcomes (including symptom management, quality of care and healthcare utilisation) in older adults (>65years) across all healthcare settings. Nine randomised controlled trials (RCTs) were identified by searches of the CINAHL, PubMed and Cochrane databases. A total of 3646 older adults were included (range 72-88 years). Seven studies were conducted with community dwellers and the other two RCTs were conducted in nursing homes. Most studies did not implement a standardised ACD, or measure the impact on quality of end-of-life care or on the death and dying experience. All studies had some risk of bias, with most scoring poorly on the Oxford Quality Scale. While ACP interventions are well received by older adults and generally have positive effects on outcomes, this review highlights the need for well-designed RCTs that examine the economic impact of ACP and its effect on quality of care in nursing homes and other sectors.

How many people will need palliative care in 2040? Past trends, future projections and implications for services

“…A third key approach is to focus efforts earlier in the disease course. Interventions such as advance care planning may allow needs to be met in line with patient preferences as illness progresses [45]. To achieve this, prospective identification of advanced disease and potential palliative care need is vital.…”

Upstreaming and Normalizing Advance Care Planning Conversations—A Public Health Approach

“…In the past, ACP has often been focused on the completion rates of actual advance directive documents, despite the lack of evidence to support that such documents improve end-of-life care or correspond with future care preferences [4]. Although evidence remains insufficient that ACP documentation leads to engagement of health care professionals in end-of-life discussions, we argue that upstreaming these conversations into lay communication may heighten the “normalization” of the topic into mainstream dialogue [5].…”

End-of-life care bonus promoting end-of-life care in nursing homes: An 11-year retrospective longitudinal prefecture-wide study in Japan

“…Since most elderly people who require a discussion about their EOL care have insufficient ability to make decisions (31), ACP is important (32)(33)(34)(35)(36). In nursing home settings, it is also effective in fulfilling residents' wishes for their EOL care and avoiding undesired medical treatment (11,37); however, ACP had been not widespread among nursing homes in developed countries including Japan (11,38,39).…”