Advance care plans in UK care home residents: a service evaluation using a stepped wedge design

Abstract

Introduction advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. Methods a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. Results About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1–1.6, P < 0.001). Hospital admission rates and bed occupancy did not differ after implementation. Discussion About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced.

Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial)

“…Hospitalization rates of NH residents are with almost 50% exceedingly high in Germany [ 40 ]; prior data show that ACP may reduce the rate of non-beneficial and/or unwanted hospitalizations, which are a major concern of many nursing home residents and have significant implications on health care costs and resource utilization [ 16 ]. However, it must be borne in mind that lowering hospitalization rates is not a goal of ACP in itself; rather, it is empirically known that many frail elderly people choose their home as their preferred place of death [ 41 ]. Thus, hospitalization may count as an acceptable surrogate parameter for care consistency; at the same time, it should be viewed together with data on care preferences.…”

Understanding advance care planning in care homes throughout the COVID-19 pandemic: A critical realist review and synthesis

“…12 Sustaining these ongoing discussions which allow residents and relatives to share care preferences with care home staff during the pandemic and beyond is important, given these discussions have been found to increase the quality of care provided and proportion of residents dying in their preferred place of death. 13…”

“…12 Sustaining these ongoing discussions which allow residents and relatives to share care preferences with care home staff during the pandemic and beyond is important, given these discussions have been found to increase the quality of care provided and proportion of residents dying in their preferred place of death. 13 It has been well acknowledged that challenges in the provision of advance care planning have existed long before the COVID-19 pandemic, such as a lack of engagement and reluctance from care home staff initiating conversations, 9,14 insufficient knowledge and skills of care home staff, 15,16 and low uptake of care planning particularly for residents with some level of cognitive impariment. 17 However, emerging evidence suggests that the pandemic has further disrupted advance care planning with decreased levels of care planning in care homes and fewer residents being able to express their wishes.…”

Advance Care Planning: ein Konzept zur Stärkung der Autonomie pflegebedürftiger Menschen (nicht nur) am Lebensende

“…Der systemimmanenten Tendenz zu standardisiertem Vorgehen ist eine konsequente, kontinuierliche Orientierung an Wunsch und Willen der einzelnen Person entgegenzustellen, die zu gewährleisten einen gesellschaftlichen Willen und gesellschaftliche Ressourcen erfordert -und eine individuelle Haltung, die Selbstbestimmung im Allgemeinen und für diese vulnerable Personengruppe im Besonderen als ein schützenswertes und förderwürdiges Recht respektiert. (Garden et al 2022;Hickman et al 2004;Klemmt et al 2021). Vielmehr möchte eine Mehrheit dieser Menschen Belastungen und Risiken lebenserhaltender Maßnahmen in einem solchen Fall nach den eigenem Vorstellungen diesseits des medizinisch Machbaren begrenzen -sei es, dass ihnen der Tod auf natürlichem Wege aus den unterschiedlichsten Gründen schlicht willkommen geworden ist oder sei es, dass sie Die Details der Umsetzung regelt eine Vereinbarung zwischen dem GKV-Spitzenverband und den Trägerverbänden der Einrichtungen vom 13.12.2017.…”

“…Sie bezieht sich vielmehr auf die Gesamtgruppe der pflegebedürftigen Personen, die in den dort genannten Settings, aber auch im ambulanten Sektor leben. Für diese Menschen bietet der geltende akutmedizinische Standard objektiv weniger Nutzen, geringere Chancen und höheren Schaden als für Gruppen mit einem geringeren Grad auf der Clinical Frailty Scale, und er stößt bei ihnen empirisch dement-sprechend weniger selbstverständlich in seiner ganzen Breite auf Zustimmung der Betroffenen -wenn man ihnen denn Gelegenheit gibt, sich dazu zu äußern (Garden et al 2022).…”