Relationship between implementation of systematic advance care planning and the quality of death among nursing home residents: a survey

Abstract

Background: Advance care planning (ACP) is beneficial for the quality of death (QOD). However, the effects of ACP on the QOD may vary across cultures.

Objectives: This study aimed to explore the relationship between the 15-step ACP program and the QOD among Japanese nursing home residents.

Design: A cross-sectional survey.

Methods: A cross-sectional survey was conducted among the family members of 39 nursing home residents who died between April 2017 and March 2019 by distributing the survey questionnaire by post. The survey included questions about the QOD of residents, and responses were evaluated using the Good Death Inventory (GDI) scale.

Results: Responses were obtained from 30 of the 39 bereaved families (76.9%). Data were analyzed using hierarchical clustering to determine five groups and conduct multiple comparisons. The following three domains of interest were identified: 'Dying in a favorite place', 'Good relationship with the medical staff', and 'Independence'. GDI scores were significantly higher for residents with higher ACP completion rates than for those with lower rates (p < 0.01). Residents who had taken ACP interviews had significantly higher GDI scores (p < 0.01) than those who had not taken interviews.

Conclusion: Overall, these findings suggest that systematic ACP might be related to the QOD among Japanese nursing home residents in the above mentioned three domains. Limitations of the present study were small sample size, cross-sectional survey design as opposed to a cohort survey design, and multiple biases, including the emotional instability of bereaved family members, the length of stay of the residents, the degree of dementia of the residents, and their tendency to talk about the place of death and to develop good relationships with the medical staff.

Keywords: advance care planning; communication training; nursing home; quality of death.

Figure 1.

Multiple comparison analysis of the five groups classified via cluster analysis. Hierarchical cluster analysis was performed based on GDI scores and demographic characteristics of 30 participants. Five distinct groups were extracted: Groups 1–5. G1–G5 denote Groups 1 to 5. Multiple comparison analyses were performed using Holm method for each of the 10 GDI domains from Q01 to Q10 among G1–G5. Of the 10 domains, 4 showed significant differences between the five groups (adjusted p < 0.01 using the Holm method). These domains were Q02: Dying in a favorite place, Q04: Good relationship with medical staff, Q07: Independence, and Q10: Life completion. The bars denote the mean GDI score in each domain for the five groups and the error bars denote 95% confidence intervals. *Adjusted p value < 0.01. **Adjusted p value < 0.001. GDI, Good Death Inventory.

Figure 2.

Relationship between ACP completion rates in each of the five groups and four GDI domains showing significant group differences. G1–G5 denote Groups 1 to 5 classified via cluster analysis. The GDI domains are as follows: Q02: Dying in a favorite place, Q04: Good relationship with medical staff, Q07: Independence, and Q10: Life completion. The ACP completion rates and the number of cases are indicated below the group names. Of the lines connecting G1–G5 and the four core GDI domains, the line on the left was negatively significant and the line on the right was positively significant. The dotted line indicates a significant difference compared with the other groups (adjusted p < 0.01), whereas the solid line indicates a large significant difference compared with the other groups (adjusted p < 0.001). The group located at the upper part of the figure has a higher ACP completion rate than the group located at the lower part. Similarly, the group located at the upper part of the figure has more positive significant differences in GDI score for each domain, whereas the group located at the lower part has more negative significant differences. In contrast, there is a negative significant difference in the GDI Q10 score in Group 5, despite the inclusion of other domains with positive significant differences. ACP, advance care planning; GDI, Good Death Inventory.