Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model

Abstract

Background: Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders’ vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations. Aim: To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development. Design: A structured integrative review of relevant literature. Data sources: CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018. Results: From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality. Conclusion: Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.

Reassessing advance care planning in the light of covid-19

“…Covid-19 guidance on advance care planning has largely focused on its product: a plan recording an individual’s treatment preferences 34. Yet evidence suggests that some of the main benefits that frail patients and their loved ones experience from advance care planning are strengthened relationships with each other and their clinical teams, and support through the experiences of living and dying with frailty and bereavement 6789. These benefits come largely from the conversations that constitute the planning process, particularly when these occur over time and include the patient’s family and loved ones.…”

“…Research has investigated the experiences and priorities of frail and older people in planning their care 7891114. However, few attempts have been made to collaborate with patients and their loved ones to design approaches to meet their needs 89. Thus translating evidence about patients’ priorities into best practice remains largely a matter of clinical expertise.…”

“…Thus translating evidence about patients’ priorities into best practice remains largely a matter of clinical expertise. Many frail people prioritise living day to day over future planning, and conversations might first need to explore how to adjust to the new circumstances of living with frailty during the pandemic, before they feel able to look to the future 814…”

Study on advance care planning in care dependent community-dwelling older persons in Germany (STADPLAN): protocol of a cluster-randomised controlled trial

“…Therefore, successful ACP programs require a crosssectoral, multidisciplinary approach, which implies improved communication even among all healthcare providers [15]. Studies from other countries have shown that ACP can reduce distress, depression and anxiety not only in residents but also in significant others and care staff [16,17].…”

Advance Care Planning in Healthcare Systems: A Literature Review and Call to Action

“…Younger patients may need broad ACP education while elderly patients, especially those who are frail will have higher acuity and urgency for ACP. [30] The EMR is a tool to facilitate ACP by providing easy identification of patients without advance directives and documentation of ACP conversations and decisions. A review of the utility of the EMR in ACP showed its most common uses are establishing documentation templates, creating electronic order sets, and automated prompts to trigger ACP discussions.…”