Improved patient participation through advance care planning in nursing homes—A cluster randomized clinical trial

Abstract

To investigate how implementing advance care planning with a whole-ward approach impact patient participation in nursing homes. Methods This was a pair-matched cluster randomized clinical trial with eight wards in eight Norwegian nursing homes. We randomized one ward from each of the matched pairs to the intervention group. We included all patients above 70. The primary outcome was prevalence of documented patient participation in end-of-life treatment conversations. The intervention included implementation support fostering the advance care planning with patient and next of kin. Results In intervention group wards the patients participated more often in end-of-life treatment conversations (p<0.001). Moreover, the patient's preferences, hopes or worries (p=0,006) were more often documented, and concordance between treatment provided and patient preferences (p=0,037) and next of kin participation in advance care planning with the patient (p=0,056) increased. Conclusion Improved patient participation-also when cognitively impaired-is achievable when regular staff perform advance care planning in nursing homes. Next of kin can have a key role. Practice implications Patients with cognitive impairment should be included in advance care planning supported by next of kin. A whole-ward approach may be more sustainable than other approaches. Trial registration ISRCTN registry (ID ISRCTN69571462)-retrospectively registered.

Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review

“…For Process outcomes, 21 of 29 (72%) were positive, including 20 of 27 (74%) for behavior change processes (e.g., readiness) (Table 1). 17,23,46,92,101,126,127 For Action outcomes, 48 of 56 (86%) were positive, including seven of nine (78%) for patient reports of communication with surrogates 118,128 and clinicians 84,126,129 and 38 of 44 (86%) for ACP documentation 17,80,120,125,127,130 …”

“…17,23,46,92,101,126,127 For Action outcomes, 48 of 56 (86%) were positive, including seven of nine (78%) for patient reports of communication with surrogates 118,128 and clinicians 84,126,129 and 38 of 44 (86%) for ACP documentation. 17,80,120,125,127,130 For Quality of Care outcomes, 23 of 43 (53%) were positive. Although one of 10 outcomes were positive (10%) for goal concordant care, 62,89,91,131,132 seven of eight (88%) outcomes for congruence between patients and surrogates or clinicians were positive 46,83,85,100,122,133,134 ; as were seven of seven outcomes (100%) for satisfaction with communication (including three for patients, 84,111,125 three for surrogates, 62,85,118 and one for clinicians 112 ); five of 11 (45%) for satisfaction with decision-making (including three of eight (38%) for patients 64,93,128 and two of three (67%) for surrogates) 82 ; and three of seven (43%) for satisfaction with medical care (including one of five for patients (20%) 62 and three of four (75%) for surro...…”

“…[115][116][117] Clinician training interventions included communication and shared decision-making training and conversation pocket guides. 109,[118][119][120][121] One study included electronic health record templates and a family discussion guide. 89…”

“…Documentation of values and preferences AD completion, 116,122,123,127,159 documents or discussions, 17,80,120,125,127,130 Goal concordant care Via medical record review alone 62,89,96,99,128,161 or also surrogate report 91,131,132 80,121,162 spiritual well-being, 90 surrogate well-being, 123,132 symptom management, 80 peacefulness 89 10 0 (0)…”

Nursing home residents with cognitive impairment can participate in advance care planning: A qualitative study

“…Our study indicates that, following a whole‐ward approach to implementation, involving residents with cognitive impairment in ACP is possible and beneficial. More patients with cognitive impairment or reduced decision‐making capacity can contribute to (Sævareid, Thoresen et al., 2019) and benefit from ACP than previously assumed.…”