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Objective To investigate the impact of advance care planning on end of life care in elderly patients.Design Prospective randomised controlled trial.Setting Single centre study in a university hospital in Melbourne, Australia.Participants 309 legally competent medical inpatients aged 80 or more and followed for six months or until death.Interventions Participants were randomised to receive usual care or usual care plus facilitated advance care planning. Advance care planning aimed to assist patients to reflect on their goals, values, and beliefs; to consider future medical treatment preferences; to appoint a surrogate; and to document their wishes.Main outcome measures The primary outcome was whether a patient’s end of life wishes were known and respected. Other outcomes included patient and family satisfaction with hospital stay and levels of stress, anxiety, and depression in relatives of patients who died.Results 154 of the 309 patients were randomised to advance care planning, 125 (81%) received advance care planning, and 108 (84%) expressed wishes or appointed a surrogate, or both. Of the 56 patients who died by six months, end of life wishes were much more likely to be known and followed in the intervention group (25/29, 86%) compared with the control group (8/27, 30%; P<0.001). In the intervention group, family members of patients who died had significantly less stress (intervention 5, control 15; P<0.001), anxiety (intervention 0, control 3; P=0.02), and depression (intervention 0, control 5; P=0.002) than those of the control patients. Patient and family satisfaction was higher in the intervention group.Conclusions Advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.Trial registration Australian New Zealand clinical trials registry ACTRN12608000539336.

Background Advance care planning (ACP) is a well-recognized quality indicator for palliative care. Despite two decades of effort, previous studies showed that ACP-related documentation and end-of-life discussion rates remain low for palliative care patients. Although ACP is about self-determination and autonomy, studies consistently show the importance of family involvement in adult patient’s medical decision-making. Yet, research on ACP interventions with structured components targeting family member remained limited. The current study aims to evaluate the effectiveness of a structured, family-supported, patient-centred ACP programme for adult palliative care patients and their families. Methods This is a 2-arm parallel group randomized controlled trial with follow-ups at 6 and 12 months. One hundred and seventy eligible palliative care patients and their families are planned to be recruited from three hospitals, and randomized to either a structured, family-supported, patient-centred ACP programme (ACP-Family) or usual ACP care (ACP-UC) arm. The ACP-Family intervention consists of 2 sessions. The primary outcome is family’s prediction accuracy of patient’s treatment preferences at 6 months. Secondary outcomes include proportions of new ACP documentations and family-reported perception of whether the patient’s end-of-life (EOL) care preference was respected; patient’s decisional conflict; quality of communication; family’s decision-making confidence; family’s anxiety and depression; and patients’ and family members’ satisfaction of the intervention. Outcomes of the two groups will be compared using regressions and linear mixed-effects models. Discussion This study will provide rigorous scientific evidence on the effectiveness of a structured and well-design family-supported, patient-centred ACP programme for adult palliative care patients and their family members in the hospital setting. If the ACP-Family proves to be effective, it will provide a structured and systematic approach to facilitate ACP discussions involving family members. This will respond to local needs and inform international ACP practice. Trial registration ClinicalTrials.gov Identifier: NCT05935540.

IntroductionEnsuring that patients receive care that is consistent with their goals and values is a critical component of high-quality care. This article describes the protocol for a cluster randomised controlled trial of a multicomponent, structured communication intervention.Methods and analysisPatients with advanced, incurable cancer and life expectancy of <12 months will participate together with their surrogate. Clinicians are enrolled and randomised either to usual care or the intervention. The Serious Illness Care Program is a multicomponent, structured communication intervention designed to identify patients, train clinicians to use a structured guide for advanced care planning discussion with patients, ‘trigger’ clinicians to have conversations, prepare patients and families for the conversation, and document outcomes of the discussion in a structured format in the electronic medical record. Clinician satisfaction with the intervention, confidence and attitudes will be assessed before and after the intervention. Self-report data will be collected from patients and surrogates approximately every 2 months up to 2 years or until the patient's death; patient medical records will be examined at the close of the study. Analyses will examine the impact of the intervention on the patient receipt of goal-concordant care, and peacefulness at the end of life. Secondary outcomes include patient anxiety, depression, quality of life, therapeutic alliance, quality of communication, and quality of dying and death. Key process measures include frequency, timing and quality of documented conversations.Ethics and disseminationThis study was approved by the Dana-Farber Cancer Institute Institutional Review Board. Results will be reported in peer-reviewed publications and conference presentations.Trial registration numberProtocol identifier NCT01786811; Pre-results.

Background In 2018, § 132g of the German Social Code, Book V (SGB V), came into force, allowing long-term care facilities in Germany to bill statutory health insurance for advance care planning (ACP). The present study examined differences in end-of-life care structures between nursing homes that had obtained approval for billing ACP and those that had not (and do not intend to obtain this approval), as well as the extent to which ACP is available to residents beyond the scope of these billing options. Methods A nationwide cross-sectional survey was conducted in 2023 among a random sample of 1,369 German nursing homes. The questionnaire, primarily targeting nursing home management staff, aimed to evaluate hospice and palliative care structures and ACP implementation. This manuscript compares nursing homes that had obtained approval for ACP billing with those that had not received approval and had no intention of applying for it; therefore, a subset of the returned questionnaires was used for analysis. Results A total of 330 questionnaires were received (response rate 24%; mostly completed by nursing home management staff), enabling the comparison of 100 nursing homes with ACP billing approval and 68 without. ACP was more prevalent in nursing homes with billing approval (96.0% vs. 36.4%; p  < 0.001). While nursing homes with approval reported higher proportions of residents with written health care proxies (66.7% vs. 58.7%; p  = 0.049) and advance directives (68.5% vs. 55.6%; p  < 0.001), no significant difference was found in the presence of emergency plans (36.0% vs. 37.6%; p  = 0.782). Furthermore, a substantial rate of at least one of these three precautionary documents was not considered useful in cases of hospitalization or cardiac arrest. Both nursing home groups reported strong collaboration with external palliative care providers, particularly general practitioners. Conclusions ACP appears accessible in nursing homes that have obtained approval for billing ACP, as well as in those that have not. Nursing homes with approval have a higher proportion of residents with advance directives. However, the limited presence of emergency plans and concerns about the utility of the three precautionary documents highlight the need for quality assurance in ACP consultation and documentation.

Background Since 2018, German nursing homes have been able to reimburse advance care planning (ACP) at the expense of statutory health insurance. ACP is a consultation for end-of-life care in which care preferences can be documented. The consultation is conducted by facilitators, who have completed the required training. However, limited research exists on how the ACP consultation processes are realized. Hence, this focus group study, as a part of the “Gut-Leben” research project, investigated its implementation. Methods Twenty-four ACP facilitators participated in four semi-structured focus groups conducted between July and September 2023. The first three focus groups were held in person with participants from Lower Saxony and Bremen, and the fourth was conducted digitally to include facilitators from other federal states in Germany. The interview guide was developed with the project’s practice advisory board in advance. The analysis was performed using deductive-inductive content analysis based on Kuckartz and Rädiker. Results The facilitators’ average age was 51.7 years (range 30–70), with 75.0% being female ( n  = 18). Facilitators typically reached out to residents proactively with the support of the nursing staff, who acted as intermediaries and helped to establish contact between the facilitators and the residents and/or relatives. Residents and relatives rarely approached the facilitators. The ACP consultation process varied in length and frequency, beginning with an initial information meeting and followed by further meetings if needed. Update meetings could be scheduled at any time, particularly in response to changes in residents’ preferences or health status, but were implemented frequently. The consultation process and the documents created during the consultation, above all the living wills, were described as very complex, especially for cognitively impaired people, which is why standardized and simplified documents are desirable. Conclusions The results indicate that ACP is highly individualized, varying by resident. However, there is a rough standardized procedure for the process, which, like the documents, could be very complex. ACP must be more widely promoted to raise awareness, reduce inhibitions, and simplify the initiation of consultation processes. Besides, ACP must also be integrated into the structure of nursing homes as a fixed procedure.

Background: Advance Care Planning is an iterative process of discussion, decision-making and documentation about end-of-life care. Advance Care Planning is highly relevant in palliative care due to intersecting clinical needs. To enhance the implementation of Advance Care Planning, the contextual factors influencing its uptake need to be better understood. Aim: To identify the contextual factors influencing the uptake of Advance Care Planning in palliative care as published between January 2008 and December 2012. Methods: Databases were systematically searched for studies about Advance Care Planning in palliative care published between January 2008 and December 2012. This yielded 27 eligible studies, which were appraised using National Institute of Health and Care Excellence Quality Appraisal Checklists. Iterative thematic synthesis was used to group results. Results: Factors associated with greater uptake included older age, a college degree, a diagnosis of cancer, greater functional impairment, being white, greater understanding of poor prognosis and receiving or working in specialist palliative care. Barriers included having non-malignant diagnoses, having dependent children, being African American, and uncertainty about Advance Care Planning and its legal status. Individuals’ previous illness experiences, preferences and attitudes also influenced their participation. Conclusion: Factors influencing the uptake of Advance Care Planning in palliative care are complex and multifaceted reflecting the diverse and often competing needs of patients, health professionals, legislature and health systems. Large population-based studies of palliative care patients are required to develop the sound theoretical and empirical foundation needed to improve uptake of Advance Care Planning in this setting.

Context: The legal tools of health care advance planning have substantially changed since their emergence in the mid-1970s. Thirty years of policy development, primarily at the state legislative level addressing surrogate decision making and advance directives, have resulted in a disjointed policy landscape, yet with important points of convergence evolving over time. An understanding of the evolution of advance care planning policy has important implications for policy at both the state and federal levels. Methods: This article is a longitudinal statutory and literature review of health care advance planning from its origins to the present. Findings: While considerable variability across the states still remains, changes in law and policy over time suggest a gradual paradigm shift from what is described as a \"legal transactional approach\" to a \"communications approach,\" the most recent extension of which is the emergence of Physician Orders for Life-Sustaining Treatment, or POLST. The communications approach helps translate patients' goals into visible and portable medical orders. Conclusions: States are likely to continue gradually moving away from a legal transactional mode of advance planning toward a communications model, albeit with challenges to authentic and reliable communication that accurately translates patients' wishes into the care they receive. In the meantime, the states and their health care institutions will continue to serve as the primary laboratory for advance care planning policy and practice.

Background Many patients have mixed feelings about end-of-life care, even when facing life-limiting conditions. Motivational interviewing might be useful for supporting patients in evoking reasons for advance care planning. This study aimed to examine the effects of an advance care planning program adopting motivational interviewing among palliative care patients. Methods A two-arm parallel randomized controlled trial was conducted between January 2018 and December 2019 in the palliative care clinics of two hospitals. Adult patients who were newly referred to palliative care services, with a score of 60 or higher in the Palliative Performance Scale and mentally competent, were eligible for the study. While all participants received palliative care as usual care, those in the intervention group also received the advance care planning program through three home visits. The primary outcome was the readiness to discuss and document end-of-life care decisions, and the secondary outcomes included decisional conflict, perceived stress, and quality of life. Results A total of 204 participants (mean [SD] age, 74.9 [10.8]; 64.7% male; 80.4% cancer) were recruited. Generalized estimating equation analyses showed a significant improvement in readiness for advance care planning behaviors in the intervention group compared with the control group at 3 months post-allocation (group-by-time interaction, appointing proxy: β  = 0.80; 95% CI, 0.25–1.35; p  = .005; discussing with family: β  = 0.76; 95% CI, 0.22–1.31; p  = .006; discussing with medical doctors: β  = 0.86; 95% CI, 0.30–1.42; p  = .003; documenting: β  = 0.89; 95% CI, 0.36–1.41; p  < .001). The proportions of signing advance directives and placing a do-not-attempt cardiopulmonary resuscitation order were significantly higher in the intervention group, with a relative risk of 3.43 (95% CI, 1.55–7.60) and 1.16 (95% CI, 1.04–1.28), respectively. The intervention group reported greater improvements in social support and value of life than the control group immediately after the intervention. Significant improvements in decisional conflicts and perceived stress were noted in both groups. Conclusions Motivational interviewing was effective in supporting patients to resolve ambivalence regarding end-of-life care, thereby increasing their readiness for discussing and documenting their care choices. Trial registration ClinicalTrials.gov Identifier: NCT04162912 (Registered on 14/11//2019).

Background In Taiwan, psychiatric patients often face premature judgments regarding cognitive impairment, emotional instability, communication barriers, or issues related to guardianship rights due to their psychiatric diagnosis. This leads to a reduction in their autonomy in healthcare decision-making. Advocacy for and experiential understanding of Advance Care Planning (ACP) among individuals with psychiatric disorders are significantly lacking. This research explores the influence of an interactive educational approach on the ACP process for psychiatric patients and whether this approach can enhance their comprehension, attitudes, and intentions regarding Advance Decisions (AD). Methods To accommodate potential variances and ensure robustness in our findings, we ultimately elected to recruit 90 participants. Using a computer-generated random number generator, we conducted a randomized trial, assigning 45 individuals to the control group and an equal number to the intervention group. The control group continued with the routine self-care educational curriculum, while the intervention group, in addition to the standard curriculum, participated in bi-weekly intervention sessions for three months. This resulted in six group health education sessions, each lasting one hour. To evaluate participants’ knowledge, attitudes, and intent to sign regarding ACP, the effects of group, time, and their interactions were assessed using Generalized Estimating Equations. Results Both groups were homogeneous at baseline. Post-intervention, Knowledge improved by 3.31 points ( p  < 0.001) and Attitude by 4.91 points ( p  < 0.001). However, the increase in Intent to Sign (0.73 points, p  = 0.222) was not statistically significant. The overarching findings indicate that the application of an interactive educational model significantly enhances psychiatric patients’ knowledge and attitudes toward ACP, although it does not substantially impact their intention to sign. Conclusions Interactive education effectively enhances psychiatric patients’ knowledge and attitudes toward ACP but does not significantly influence their intent to sign AD. We advocate for their empowerment in ACP discussions. This study highlights the feasibility of integrating ACP promotion into routine psychiatric care.