Table 1.
Study | Study design | Country | Setting | Sample | Intervention and professional involved | Primary outcome measure | ACP outcomes | Health-care outcomes | Key findings |
---|---|---|---|---|---|---|---|---|---|
Caplan et al. [17] | Controlled before and after study | Australia | Nursing homes (NHs) (n = 32) and hospitals (n = 3) | Nursing home residents (NHRs), their families, staff and general practitioners | Education for residents, families, staff and GPs | Not specified | Number of ACP referrals | Number of Emergency Department presentations and hospital admissions | ACP. In the first year, 63 NHRs referrals were received; 45 NHRs agreed to proceed with ACP. Five were judged to have capacity: discussions and decisions documented in their notes |
Potential nursing home participants n = 1,344 | Number of ACP discussions | Number of emergency ambulance calls from all the nursing homes (NHs) | Of the 40 without capacity: 3 ‘persons responsible’ completed a plan of treatment, 20 NHRs had discussions and preferences were recorded in notes but no document was signed, 10 NHRs completed discussions but nothing formally documented, 6 persons responsible declined discussion of ACP, 1 NHR had previously completed ACP | ||||||
Number of discussions that proceeded to a written form by either the resident or a proxy | Number of emergency and elective admissions to hospital and bed-days occupied by residents in hospital | Mortality. No significant change in mortality until the final third year when mortality rose in the control nursing homes (30.4 versus 41.6 deaths per 100 nursing home beds; P = 0.0425) | |||||||
Number of deaths registered to the address of each NH | Health care use. Annual rate of admission of residents per nursing home bed initially higher in the intervention hospitals, but lower by the final year (0.865 versus 1.254; RR = 0.89; 95% CI: 0.85–0.93; P < 0.0001). Risk of a resident being in an intervention hospital bed for a day compared with control group fell by a quarter from being initially similar (RR = 1.01; 95% CI: 0.98–1.04; P = 0.442) to being lower (RR = 0.74; 95% CI 0.72–0.77; P ≤ 0.0001) | ||||||||
Hanson et al. [19] | Controlled before and after study | USA | Nursing homes (n = 9) | Nursing home residents (n = 458) | Recruitment and training (in palliative care practices) of palliative care leadership in each facility | Not specified | Number of documented ACP discussions | Percentage of residents receiving hospice or palliative services, pain assessment, pain treatment among residents in pain | ACP. Documented ACP discussions were rare at baseline. Intervention NHRs had a significant increase in documented discussions from 4 to 17% (P < 0.001) |
Two nursing homes were chosen at random for training | Number of orders on life-sustaining treatments, living wills and health-care powers of attorney | DNR orders increased slightly in intervention nursing homes (58–65%, P = 0.04), as did use of DNR flags. Living wills (31% versus 30%) and health-care powers of attorney (27% versus 33%) were not significantly changed | |||||||
Patient health. Significant increase in the intervention group in pain assessment from 18 to 60% (P ≤ 0.001); no change in orders for pain medication | |||||||||
Health-care use. Significant increase in hospice enrolment in the intervention group from 4.0% at baseline to 6.8% post intervention (P ≤ 0.01) | |||||||||
Molloy et al. [18] | Randomised control trial | Canada | Nursing homes (n = 6) | Nursing home residents (n = 1,133) | Two days educational workshop for nurses in nursing homes who then trained other staff and counselled patients. Used Let Me Decide. Nurses carried out the discussions; Doctors reviewed and signed the forms | Residents’ and families’ satisfaction with health care and health-care utilisation over 18 months | Rates of completion of advance directives | Residents’ and families’ satisfaction with health care and | Satisfaction with healthcare. No significant differences between intervention and control homes |
Six nursing homes were randomly allocated to the two trial arms | Health care utilisation over 18 months | ACP . Overall, 49% of participants completed ADs. At the end of the study, 70% of NHRs in the intervention group and 57% in the control group completed ADs. In the control homes 71% of ADs were DNR orders and in the intervention homes 89% of directives were Let Me Decide | |||||||
Mortality. Similar in both intervention and control groups (24% versus 28%; P = 0.20) | |||||||||
Health-care use. Mean hospitalisation rates per patient lower in the intervention group compared with the control (0.27 versus 0.48; P = 0.001) | |||||||||
Average total cost per patient (health-care resource use) significantly less in the intervention group compared with the control group (CAD 3,490 versus CAD 5,239; P = 0.01); hospital costs per patient also less in the intervention group (CAD 1,772 versus CAD 3,869; P = 0.003). | |||||||||
Morrison et al. [20] | Non-randomised controlled trial | USA | Nursing home | Nursing home residents (n = 139) | Education, using interactive methods, in ACP for intervention group social workers. Social workers (usual care) received a talk on state law and medical decision-making | Not specified | Nursing home chart documentation of advance directives and DNR orders | Concordance of treatments received with documented preferences | ACP. Intervention residents were more likely to have their preferences documented in nursing home chart than control group residents. Significant increases in documentation of patent preferences in the intervention group compared with control: cardio pulmonary resuscitation (40% versus 20%; P = 0.005); artificial nutrition and hydration (47 versus 9%; P ≤ 0.01); intravenous antibiotics (44 versus 9%; P = 0.01) and hospitalisation (49 versus 16%; P ≤ 0.01) |
Four social workers were randomly allocated to two arms | Documentation of patient preferences for care | Health-care use. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes (P = 0.04) |
*Int, intervention; **Con, control; ***CI, confidence interval; RR, relative risk.