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Table 3 ACP tools with a chart-based focus, or Advance directive as main goal

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
Hickman SE, 2011
Oregon, Wisconsin & West Virginia,
USA
- 90 NHs
- 870 Living & deceased residents with a valid POLST
Tool:
POLST
- Cross-sectional observational study
- Quantitative methods
- Retrospective chart review
- Treatment for patients with a completed POLST mostly consistent with stated wishes:
- Over 90 % adherence in terms of resuscitation, hospitalization & antibiotics, 63.6 % in terms of feeding tubes
Standardized medical orders that transfer with them throughout the healthcare system  
Sankaran S, 2010
Aukland, New Zealand
- NH & hospital nurses
- Mental status not provided
- Multi-component support w/5main components: medication review, tel. hotline, advance nursing support POAC/Chronic Care Management programme & ACP
Education
- Learning course
- Weekly in-house education
- Practical training
- Facilitators
Intervention study 6-months. follow-up
- Mixed method
- Observation & analyses of field notes.
- Semi-structured interviews with staff pre/post intervention
- Recording of medication changes, use of emergency calls & transmission to hospital
- No ACP were completed
- All nurses but no physicians participated in the ACP-training
- ACP programme continued
- Education programme stopped
- Hotline
- Education
- Unclear legal issues
- Illnesses in the residents
- Absent physicians
- Staff was reluctance
- Lack of time
- Management thought residents’ cognitive state was too poor
- The residents were insecure, as their family was not invited to the discussion.
Caplan GA, 2006
Australia
- 1 clinical nurse consultant
- 2 hospitals, & 1 control hospital
- 21 NHs
- 45 NH patients
- MMSE ≥16 excluded
Tool
- “Let Me Decide”
Education
- Learning course
- Education of family residents & staff about dementia, ACP, alternatives to hospitalisation
- Facilitators
- Non-randomised intervention study, 12-months. follow-up
- Quantitative methods
- Controlled retrospective & prospective registry analyses over 3 years
- Changed routines, culture,
- More information to families
- Fewer deaths in hospitals
- Decreased emergency calls in intervention hospital
-Staff more confident in addressing ACP-issues
- Clarified role of the substitute consent giver
- Capacity screening for mental competence by MMSE ≥16
- Education
- Challenges relating to following groups: dementia/neurodegenerative, cardiac & respiratory end-stage disease
- Reluctance to sign the ACD document
Jeong SY, 2007
Australia
- 3 Patients
- 11 Relatives
- 13 Nurses
- Final included N not specified
Not specified - 7-months. observation study
- Mixed method
- Medical record analyses
- Observation of specialist nurses & their role in the ACP process
- Observation: residents, relatives & nurses
- Interviews of staff, patients & relatives
Themes:
- Nurses needed to clarify what ACP did & did not entail (i.e., dispelling myths such as ACP = euthanasia)
- Nurses had an important role as a communicative link between physicians, family & patient
  
Molloy DW, 2000
Ontario, USA
1292 Competent NH patients (MMSE > 16)/relatives of non-competent patients (Intervention N = 636, control N = 656) Tool
- Let Me Decide
Education
- Learning course
- Practical training
- Workshops
- Train the trainer
- Facilitators
Randomized controlled trial, follow-up at 6, 12 & 18 months.
Quantitative methods
Questionnaires to patients or patients relatives
- 49 % of residents & 78 % of relatives completed AD in intervention
- Fewer hospitalizations
- Reduced hospital costs
- Allocating personnel to ensure implementation - The form was too comprehensive; deterred residents from completing it
Markson 1994 48 Competent NH patients
356 Home care patients
10 NH or home care Physicians
   90 % of NH patients completed form   
  1. POLST physician orders for life-sustaining treatment, POAC primary options for acute care
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