Table 4 Overview of process papers
From: A review of the implementation and research strategies of advance care planning in nursing homes
Author | Population | Aim of the study? | Comparison Methods Outcome measures | Outcome/themes/results | Promoters | Barriers |
|---|---|---|---|---|---|---|
Burgess M, 2011, USA | - 9 NHs - 31 physicians - 12 nurse practitioners/physician assistants | - Identify important barriers & promoters for ACP among NH staff | - Quantitative methods - Survey | - ACP documentation habits, i.e., location & who is responsible for documenting, perceived barriers & promoters - Experiences with different ACP elements | - Standardized form - Standardized location for documentation - Training/education of staff | - Patients’ impaired cognition - Lack of time during visit - Lack of family involvement |
Stewart F, 2011 London, UK | - 34 NHs - 33 NH managers - 18 NH nurses - 10 Nurses & 29 care assistants from community - 15 Primary contact, family/friends - 14 Residents | - Qualitative Study - Semi-structured interviews about end-of-life care with staff & family members | Themes: - Benefits: choice, better planning, respect for patients wishes, aiding treatment decisions - Staff reported to have some form of ACP in place - Only 1 resident shared preferences, therefore interviews not included - Family & staff have different views about residents best interests | - Staff & family positive towards ACP; prepare for better planning - Early initiation; often too late in a NH - Family involvement - Familiarity between staff, resident & family - Staff training - ACP providing guidance to staff how to approach discussion | - Reluctant patients - Reluctant personnel, - Reluctant family involvement - Dementia - Unforeseen medical circumstances - Staffs diff. cultural beliefs, ethnic backgrounds - Family insists on hospital transfer - GPs not included-should be more engaged. | |
Froggatt K, 2009 UK | - 213 care home managers - 15 care home managers interviews | To describe current ACP practice in UK | Mixed method design in two cross-sectional phases - Questionnaire-based survey of 213 managers - Telephone based in-depth interviews | - 1/3 of the NHs had completed ACP in fewer than 25 % of the patients - 1/5 of the NHs had ACP completion in 75 % or more of the patients - 5 themes: consultation w/resident, consultation w/relative, discussing future decision making, training, manager perspective on ACP | - UK is engaged in strategy & policy initiatives for coordination of ACP - ACP Initiatives must consider implementation in which the whole system has to be considered | - Resident’s unwillingness & level of functioning, - Family unwillingness/availability/dynamic, - Staff confidence/knowledge/time/discomfort - NH resources - Extrinsic factors, i.e., GPs, district nurse & hospitals - Unclear responsibility |
Shanley C, 2009 South Western Sydney, Australia | 41 Care facility managers | To gain an understanding of how ACP is understood & approached by care facilities managers | Qualitative Study Interviews with managers Themes discussed: Initiation; Scope; Follow-up; Documentation; Organisational leadership; “In a nutshell” (individual initiative) | - Facilities without a systematic ACP approach tend to discuss EoLC late in illness - Little coherence between wishes & treatment plan - Common practice to incorporate ACP in the general care process - Conflicting ideas of ideal timing to initialize ACP | - Involve all stakeholders, - Systematic approach (i.e., guidelines, policies, protocols, checklists) - Clarified responsibility & documentation - Early initiation of ACP | - Patient & family unwillingness - Physicians’ reluctance - Legal uncertainties - Lack of training - No ACP system |
Pauls MA, 2001 Toronto, Canada | 7 nurses from Emergency Department (ED), 7 ED physicians 10 Paramedics 7 Long term care (LTC) nurses 4 LTC physicians | - Describe an ideal model for the transfer of an directive from LTC facilities to EDs - Understand the complex process in a transfer form | Qualitative study - 6 Focus group interviews with 35 participants | Theme –synthesis of the “ideal” ACP model: - Form: max 2 pp, simple language, specified options & room for alternative responses, physician’s signature - Completing the form: Education for staff, patient & family, starting early, process rather than a decision focus, yearly review, - Using the form: before acute illness, accessible, implement on regional basis, endorsed by authorities, improve staff education/communication | - Simplicity & acceptability - Physicians signature - Substitute decision maker - Education & repeated, simple info to patients & relatives - Process rather than a decision focus - Info in form of books, video, discussions - Cultural sensitivity | - In crises, physicians may not follow ADs/wishes - Minorities less likely to complete; mistrust - Unknown patients - Lack of time - Exclusion of physicians - Lack of external validity - Time consuming |