Initiation of advance care planning in newly admitted nursing home residents in Flanders, Belgium: A prospective cohort study

Abstract

Aim To describe (i) the timing of initiation of advance care planning (ACP) after nursing home admission; (ii) the association of dementia and physical health with ACP initiation; and (iii) if and how analgesic use and use of lipid modifying agents is related to ACP, in a cohort of newly admitted residents. Methods A prospective, observational cohort study of nursing home residents was carried out. Data were collected 3 months, 15 months (year 1) and 27 months (year 2) after admission, using a structured questionnaire and validated measuring tools. Results ACP was never initiated during the 2‐year stay for 38% of the residents, for 22% ACP was initiated at admission, for 21% during year 1 and for 19% during year 2 (n = 323). ACP initiation was strongly associated with dementia, but not with physical health. Residents without dementia were more likely to have ACP initiation at admission or not at all, whereas ACP initiation was postponed for residents with dementia. Between admission and year 2, analgesic use increased (from 34% to 42%), and the use of lipid‐modifying agents decreased (from 28% to 21%). Analgesic use increased more in residents with ACP initiation during year 1 and year 2. The use of lipid‐modifying agents was not associated with ACP. Conclusions The timing of ACP initiation differed significantly for residents with and without dementia, which highlights the importance of an early onset of ACP before residents lose their decision‐making capacity. ACP conversations might create opportunities to discuss adequate pain and other symptom treatment, and deprescribing at the end of life. Geriatr Gerontol Int 2019; 19: 141–146.

Implementing the theory-based advance care planning ACP+ programme for nursing homes: study protocol for a cluster randomised controlled trial and process evaluation

“…Research shows that only a minority of older people actively engage in ACP, and that there is still a low prevalence of ACP in Flemish nursing homes [6,19]. Nonetheless, a majority of the growing population of older people would appreciate an opportunity for such discussions and planning [20,21].…”

“…In addition, very few randomised controlled trials (RCT) in this area have been published [3]. Moreover, the uptake of ACP in clinical practice remains limited and nursing home residents' wishes about their preferred medical treatment and care are often not, or not in time, explored [4][5][6]. Previous epidemiological studies have shown that uptake is also low in Belgium where only half of deceased nursing home residents had documented wishes or preferences [7] and 38% of residents never engaged in ACP during their two-year stay in a nursing home [6].…”

“…GPs are invited to an information session after 5 p.m., accreditation can be arranged. As part of 'in-house training' component(6) Activity 11&12: In-house 2-h training sessions (session 1 & 2) to train 'ACP Conversation Facilitators' in performing ACP conversations Activity 13: In-house 1,5-h training session to train 'ACP Antennas' to educate them how to recognize triggers in residents and family, so they are more willing to have spontaneous ACP conversations according to their competencies and so they know how to pass on information to other staff As part of the ACP planned conversation(s) (7) Activity 14: Exploration of earlier wishes and GP involvement. Activity 15: First planned ACP conversation with resident and family Activity 16: ACP follow-up conversation(s) Activity 17: Documentation of wishes and preferences As part of 'information transfer' component(8) Activity 18: Integration of ACP into multidisciplinary meetings so information is shared across professionals in the nursing home As part of 'coaching' component (9) Activity 19: One-to-one coaching on request, by ACP Trainer to nursing home staff Activity 20: In-house specialization session 1 (at least 2 hrs): Dementia Activity 21: In-house specialization session 2 (at least 2 hrs): Communication with other healthcare professionals As part of 'audit' component(10) Activity 22: ACP audit meeting(s) to discuss ACP procedures with all involved healthcare professionals, the coordinating advisory physician and the management to identify problems and discuss action plans for improvement…”

Advance Care Planning for People with Dementia: The Role of General Practitioners

“…Many people only enter a nursing home when their cognitive abilities no longer allow them to remain in their own domestic environment. It has also been shown that after entering a nursing home the moment for initiating ACP is often missed [34] or the ACP process is inadequately implemented [35], also clearly hinting at the usefulness of an early initiation of the ACP process in healthy days of life.…”

Parents’ experiences of initiation of paediatric advance care planning discussions: a qualitative study

“…Unlike the adult setting, pACP is surrounded by a range of legal and ethical issues with regards to a minor's capacity to consent and the influence of parents and HCP as surrogate decision makers [17]. Despite such differences most research on ACP initiation is adult-centred [18][19][20], with a dearth of research exploring the concept in children's settings.…”