Evaluating if an Advance Care Planning Intervention Promotes Do-Not-Resuscitate Orders by Facilitating Accurate Prognostic Awareness

Abstract

Background: Issuing do-not-resuscitate (DNR) orders has seldom been an outcome in randomized clinical trials of advance care planning (ACP) interventions. The aim of this study was to examine whether an ACP intervention facilitating accurate prognostic awareness (PA) for patients with advanced cancer was associated with earlier use of DNR orders. Patients and Methods: Participants (n=460) were randomly assigned 1:1 to the experimental and control arms, with 392 deceased participants constituting the final sample of this secondary analysis study. Participants in the intervention and control arms had each received an intervention tailored to their readiness for ACP/prognostic information and symptom-management education, respectively. Effectiveness in promoting a DNR order by facilitating accurate PA was determined by intention-to-treat analysis using multivariate logistic regression with hierarchical linear modeling. Results: At enrollment in the ACP intervention and before death, 9 (4.6%) and 8 (4.1%) participants and 168 (85.7%) and 164 (83.7%) participants in the experimental and control arms, respectively, had issued a DNR order, without significant between-arm differences. However, participants in the experimental arm with accurate PA were significantly more likely than participants in the control arm without accurate PA to have issued a DNR order before death (adjusted odds ratio, 2.264; 95% CI, 1.036–4.951; P=.041). Specifically, participants in the experimental arm who first reported accurate PA 31 to 90 days before death were significantly more likely than their counterparts in the control arm who reported accurate PA to have issued a DNR order in the next wave of assessment (adjusted odds ratio, 13.365; 95% CI, 1.989–89.786; P=.008). Both arms issued DNR orders close to death (median, 5–6 days before death). Conclusions: Our ACP intervention did not promote the overall presence of a DNR order. However, our intervention facilitated the issuance of NDR orders before death among patients with accurate PA, especially those who reported accurate PA 31 to 90 days before death, but it did not facilitate the issuance of DNR orders earlier than their counterparts in the control arm.ClinicalTrial.gov Identification: NCT01912846

Advance Care Planning Engagement Among Family Members of Community-Dwelling Elderly Patients With Chronic Diseases in China

“…[7][8][9] In developed countries, the advantages of ACP have been well documented with comprehensive, in-depth research on a wide range of research populations, including adolescents, adults, the elderly, and their families. 10,11 In China, the population focused on in research are patients with advanced cancer or in the terminal stage 12,13 ; family members are rarely included. The research content is also mainly focused on knowledge of and attitude toward ACP, 14 and there are few behavior studies on ACP participation.…”

Effect of a Video-Supported Nurse-Led Advance Care Planning for Older Adults with Frailty: A Randomized Controlled Trial

“…The recent systematic reviews on the efficacy of ACP based on 132 RCTs concluded that it improved ACP documentation, with 34 out of 54 included studies (63%) showing significant and positive results [12]. However, amongst these 54 RCTs, only three were conducted in Asian countries [28,30,31]. Together with a more recent RCT in Singapore, mixed results on ACP/AD documentation were found: two showed significant improvement in the outcome [28,30], and the other two had non-significant results [31,32].…”

“…However, amongst these 54 RCTs, only three were conducted in Asian countries [28,30,31]. Together with a more recent RCT in Singapore, mixed results on ACP/AD documentation were found: two showed significant improvement in the outcome [28,30], and the other two had non-significant results [31,32]. Compared with our previous RCT on ACP conducted in Hong Kong with significant results on ACP/AD documentation [28], we did not observe a difference in the AD completion rate between the two groups although we have added the 3-min video decision aid in the ACP intervention in the current study.…”

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

“…DNR orders: None of the five RCTs that explored the effect of ACP on do-not-resuscitate (DNR) orders found a significant association 52 69 131 150 151…”