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

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