Changes in Advance Care Planning for Nursing Home Residents During the COVID-19 Pandemic

Abstract

Objective: Describe the care preference changes among nursing home residents receiving proactive Advance Care Planning (ACP) conversations from health care practitioners during the COVID-19 pandemic. Design: Retrospective chart review. Setting and Participants: Nursing home residents (n ¼ 963) or their surrogate decision makers had at least 1 ACP conversation with a primary health care practitioner between April 1, 2020, and May 30, 2020, and made decisions of any changes in code status and hospitalization preferences. Methods: Health care practitioners conducted ACP conversations proactively with residents or their surrogate decision makers at 15 nursing homes in a metropolitan area of the southwestern United States between April 1, 2020, and May 30, 2020. ACP conversations reviewed code status and goals of care including Do Not Hospitalize (DNH) care preference. Resident age, gender, code status, and DNH choice before and after the ACP conversations were documented. Descriptive data analyses identified significant changes in resident care preferences before and after ACP conversations. Results: Before the most recent ACP discussion, 361 residents were full code status and the rest were Out of Hospital Do Not Resuscitate (DNR). Of the individuals with Out of Hospital DNR, 188 residents also chose DNH. After the ACP conversation, 88 residents opted to change from full code status to Out of Hospital DNR, thereby increasing the percentage of residents with Out of Hospital DNR from 63% to 72%. Almost half of the residents decided to keep or change to the DNH care option after the ACP conversation. Conclusion and Implications: Proactive ACP conversations during COVID-19 increased DNH from less than a quarter to almost half among the nursing home residents. Out of Hospital DNR increased by 9%. It is important for all health care practitioners to proactively review ACP with nursing home residents and their surrogate decision makers during a pandemic, thereby ensuring care consistent with personal goals of care and avoiding unnecessary hospitalizations.

Impact of the COVID-19 pandemic on end of life care delivery in care homes: A mixed method systematic review

“…Of the included studies, four were qualitative, 24–27 three used a mixed method design 15,28,29 and two were quantitative. 14,30 The studies included populations from nine countries, including the UK ( N = 3), 15,25,26 Sweden ( N = 2), 14,30 Ireland ( N = 2), 15,28 Spain ( N = 1), 24 Italy ( N = 1), 24 Mexico ( N = 1), 24 Peru ( N = 1), 24 Pakistan ( N = 1) 27 and the USA ( N = 1) 29 (Table 2). Participants in five studies consisted of care home staff, which included registered nurses, home managers and non-registered staff such as care assistants and domiciliary staff.…”

“…The increased importance of care planning discussions in advance of end of life care during the COVID-19 pandemic in care homes was noted by several studies. 14,28,29 Ye et al, 29 conducted a retrospective chart analysis of n = 963 residents and their surrogate decision makers from 15 nursing homes in Texas, USA between April 1, 2020 and May 30, 2020. The study found that advance care planning discussions during the COVID-19 pandemic led to increased numbers of residents changing their wishes.…”

“…Specifically, several studies suggest decreased advance care planning and end of life discussions with residents and relatives. 14,28,29 Strang et al 14 analysed the national Swedish Register of Palliative Care to compare deaths in care homes during COVID-19 to pre-pandemic deaths, n = 908 expected COVID-19 deaths in care homes were analysed. Although results do not suggest changes in advance care planning discussions occurred for all residents during the pandemic, the study did find that fewer care planning discussions were taking place compared to pre-pandemic data, with 35% fewer residents being able to retain the ability to express their wishes during the last weeks of life.…”

“…Furthermore, analysis identified that the unpredictable and unplanned decline of residents with COVID-19 coupled with fewer care planning conversations led to more unnecessary admissions to hospital at the end of life. 14,29 This situation may have contributed to the increase in residents dying without their relatives and friends around them. 14,28 The reasons behind the decreased occurrence of advance are planning and end of life discussions varied between studies.…”

Implementation of advance care planning amid the COVID‐19 crisis: A narrative review and synthesis

“…In total, 20 articles were included, of which eight were primary studies incorporating 5542 participants. The design of the primary studies was retrospective observational ( n = 4), 17–20 comparative cross‐sectional ( n = 1), 21 design process ( n = 2), 22,23 quality improvement intervention ( n = 1), 24 case report/study ( n = 2) 25,26 and virtual workshop ( n = 1) 27 . The rest of the articles were perspective papers ( n = 5), 3,28–31 letters to the editor ( n = 2), 32,33 newspaper analysis ( n = 1) 34 and guideline review ( n = 1) 35 .…”