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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
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
- 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
- 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
  1. ACP advance care plan(ning), AD advance directive, ED emergency department, EoLC end of life care, LTC long term care