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Table 2 Clinical intervention studies

From: A review of the implementation and research strategies of advance care planning in nursing homes

Author Population Intervention-tool/education/aim of the study? Comparison
Methods
Outcome measures
Outcome/themes/results Promoters Barriers
Livingston G, 2013
London, UK
Patients w/dementia who died before (N = 98), during (N = 56) or after (N = 42) the intervention
mean MMSE = 5
Tool
- GSFCH
- Chart for choices
Education
- Learning course
- 10-session manualized, interactive staff-training program Practical training
- Facilitators
- Non-randomized intervention study, 2-year follow-up
- Mixed methods
- Interviews w/relatives
- Review of med. records
- QoL-AD, GHQ, DNR, ACP, days in hospital
- Better palliative approach
- Fewer deaths in hospitals (from 76 to 47 %)
- Better documentation of DNR orders (from 14 to 73 %) & ACP discussions (from 39 to 65 %)
- No difference for days spent in hospital
- More satisfied relatives
- Staff more comfortable with addressing ACP-issues
- Staff training to increase awareness & knowledge & reduce fear
- Motivated NH management
- Trained in Gold Standard Framework
- Low staff turn over
- Different dementia policy actions at the same time-change findings
- Different cultures? Laws (e.g., Jewish tradition NH)
- Adaption addressing different cultures in NHs necessary
Silvester W, 2013
Victoria area, Australia
19 Residential Aged Care Facilities (RACF)
203 Patients’ records
Cognitive function not specified
Tool
Making Health Choices
- Non-randomized controlled trial
- Quantitative methods
- Analysis of patient records, documented ACP pre/post-intervention timeframe not specified
- Better documentation of EOLC preferences & ACP discussions
- 49 % MEPOA
- >90 % value/beliefs
- 78 % health perspectives
- Standards guiding ACP content & documentation
- Ex. of values/belief statements in care plans
- 17 principles of ACP (e.g., policies, education, information, routines, best interest, Inevitability of death, options, GP, EOLC, documentation confidentiality)
- Inconsistencies in naming & layout of ACP documentation
Hockley J, 2010, Scotland,
UK
7 NHs
133 patients assessed as in need of ACP, who died during intervention, 95 controls (patients who died a year prior to intervention)
66 % were diagnosed with dementia
Tool
- GSFCH
- LCP
Education
- Learning course
- Practical training
- Workshops
- Train the trainer
- Facilitators
- Support from researchers
- Intervention study, 18-months. follow-up
- Mixed methods
- Chart review
- Survey of health care personnel
- Qualitative interview of bereaved relatives (results not reported)
- Better palliative approach
- Fewer hospital deaths
- Staff comfortable with addressing ACP-issues
- Good consistent leadership
- Regular visits from the same GP
- More comprehensive palliative care approach
- Problems with staff turnover, retention & recruitment
Chan HY, 2010
Hong Kong
Competent NH patients:
- 59 intervention
- 62 control
Tool
- Let me Talk
Education
- Semi-structured interview guide
- Non-randomized controlled feasibility study, 12-months. follow-up
- Quantitative methods
- Questionnaire based survey
- Only 3 families included
- Stability of treatment preference
- More preference stated
- Relieved existential anxiety/distress
  - Time consuming
- Unclear effect in incompetent people/with dementia & older people
Morrison RS, 2005
NY City, USA,
- 4 Social workers (2 control/intervention)
- 139 LTC residents:
96 control
43 intervention
Tool
- Structured ACP discussion with patient & relatives at admission, 1 year & changes in clinical status
Education
- Counselling of NH social workers
- Education/training: Terms/definitions, role-play, supervision
- Practical training
- Workshops
- Controlled clinical trial, 6-months. follow-up
- Mixed methods
- Minimum data set at admission
- Interview of Social workers
- Review of medical records
- Better documentation of EOLC preferences & ACP discussions
- Better concordance between patient wishes & provided treatment
- High focus on decision capacity & proxy relative
- Simple intervention of forms, team meetings, feedback to clinicians by social workers improves likelihood of residents preferences being elicited
- Few social workers
- Lack of documentation
- Short follow up
- Legislation restricting surrogate decision making on behalf persons with reduced decision capacity
  1. ACP advance care plan(ning), EOLC end of life care, GSFCH gold standards framework for care homes, LCP liverpool care pathway, MEPOA medical enduring power of attorney, QoL-AD, GHQ, DNR, ACP