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

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.

Design: Systematic review.

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.

Keywords: Advance Care Planning; advance directive; aged care facility; nursing home.