Review Article
The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review

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Abstract

Background

Advance care planning (ACP) encompasses a process by which people may express and record their values and preferences for care and treatment should they lose the capacity to communicate them in the future. We believe the effects that ACP can have on the nursing home population is distinct from others and sought to gain insight into the outcomes of relevant studies on the topic.

Aim

To identify the effects of ACP interventions on nursing home residents.

Methods

A comprehensive literature search was conducted using the following 4 electronic databases, Embase, Medline, PsychINFO, and CINAHL, with no limits on year or language. Gray literature search of relevant journals was also performed as was reviewing of the reference lists of all included articles. Inclusion criteria were randomized controlled trials, controlled trials, pre/post study design trials and prospective studies examining the effects of ACP on nursing home residents. A detailed narrative synthesis was compiled as the heterogeneous nature of the interventions and results precluded meta-analysis.

Results

The initial search yielded 4654 articles. Thirteen studies fitted inclusion criteria for analysis. The ACP interventions included (1) 5 studies evaluating educational programs; (2) 5 studies introducing or evaluating a new ACP form; (3) 2 studies introducing an ACP program with a palliative care initiative; and (4) 1 study observing the effect of do not resuscitate orders on medical treatments for respiratory infections. A range of effects of ACP was demonstrated in the study populations. Hospitalization was the most frequent outcome measure used across the included studies. Analysis found that in the nursing home population, ACP decreased hospitalization rates by 9%–26%. Of note, in the 2 studies that included mortality, the decrease in hospitalization was not associated with increased mortality. Place of death is another important effect of ACP. Analysis found significant increases in the number of residents dying in their nursing home by 29%–40%. Medical treatments being consistent with ones' wishes were increased with ACP although not to 100% compliance. Two studies showed a decrease in overall health costs. One study found an increase in community palliative care use but not in-patient hospice referrals.

Conclusions

ACP has beneficial effects in the nursing home population. The types of ACP interventions vary, and it is difficult to identify superiority in effectiveness of one intervention over another. Outcome measures also vary considerably between studies although hospitalization, place of death, and actions being consistent with resident's wishes are by far the most common. Very few studies with high quality methodology have been undertaken in the area with a significant lack of randomized controlled trials. More robust studies, especially randomized controlled trials, are required to support the findings.

Section snippets

Design

This systematic review has been prospectively registered with PROSPERO.36

Search Strategy

In April 2015, a comprehensive literature search was conducted using the following 4 electronic databases, Embase, Medline, PsychINFO, and CINAHL, with no limits on year or language. The search strategy is available for review in Figure 1. The search yielded 4654 titles. There were no restrictions by study design at this time so as to allow identification of all studies related to the question. Hand-searching of citations

Study Characteristics

Seven of the studies took place in the USA, 1 took place in Australia, 1 in Hong Kong, 1 in Canada, 1 in the United Kingdom, 1 in Singapore, and in The Netherlands. The intervention in 5 studies was an educational program. For 2 of these, the ACP education was provided just to healthcare staff,39, 40 whereas in the other 3, education was provided to healthcare staff, residents, and families.28, 29, 41 Five studies involved introduction or evaluation of a new ACP form in the facility.32, 42, 43,

Interventions

Findings from this review show beneficial effects for ACP interventions in the nursing home population, but the evidence supporting the findings is of generally low quality. The variability in the interventions was considerable, but over 75% could be classified broadly into 2 categories: (1) educational programs; or (2) introduction and evaluation of a new ACP in the facilities. Five of the 13 studies took either an educational approach for staff or an educational approach for staff, families,

Conclusions

The data on ACP interventions shows beneficial effects in nursing home populations; the most important of which include actions being consistent with the person's wishes and avoidance of unwanted hospitalization and life-sustaining treatments. The available evidence is generally not of high quality. Most studies in the area are of retrospective designs and, as a consequence, 44 such studies were excluded from this review.

ACP is important for frail older people where the possibility of

Key Points

  • The nursing home population has unique characteristics for ACP.

  • ACP has beneficial effects for the nursing home population.

  • ACP leads to actions being more consistent with resident's wishes.

  • ACP decreases unwanted hospitalization and use of life-sustaining treatments, and increases probability of dying in the nursing home.

  • ACP is important for decreasing unwanted medical interventions at end-of-life

  • ACP can decrease healthcare costs.

  • The effects found are mainly from pooled low quality studies

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    The authors declare no conflicts of interest.

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