The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials

Abstract

Background:No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced cancer, and the mechanisms of action in relation to the intended outcomes.Aim:To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes.Design:A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative synthesis was used for data analysis.Data sources:The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality appraisal.Results:Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which advance care planning improved outcomes comprised (1) increasing patients’ knowledge of end-of-life care, (2) strengthening patients’ autonomous motivation, (3) building patients’ competence to undertake end-of-life discussions and (4) enhancing shared decision-making in a trustful relationship. Samples were largely highly educated Caucasian.Conclusion:The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they identify the individual behavioural change. Strengthening patients’ motivation and competence in participating advance care planning discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and ethnicities in non-Western countries should be a research priority.

Decision support intervention (Plan Well Guide) for patients and their substitute decision-makers to improve engagement in advance care planning: protocol for a randomised trial

“…The tool is scripted and structured with the intention of non-facilitated use; however, the interactive online version was not available when this trial began. The decision aid intervention has not been translated to languages other than English or adapted for varying cultures, therefore, study participants may represent the typical Caucasian English speaking more educated population as found in many previous studies of ACP 47. Successful models of adapting ACP tools for other populations exist48 and should be considered in the future.…”

Planificación de los cuidados en el final de la vida. Perspectivas de profesionales de oncología y cuidados paliativos

“…(Oncólogo, Patagonia) Estos fragmento dan cuenta de la importancia de los aspectos organizacionales de los servicios de salud para la implementación de este tipo de abordajes, aspecto que suele ser poco considerado en las intervenciones tendientes a adoptar la planificación del cuidado en el final de la vida. Como lo ha mostrado revisiones recientes (Lin et al, 2019), estas iniciativas suelen apuntar al cambio de comportamiento a nivel individual (sensibilizar y modificar actitudes los/as profesionales y de las personas en fin de vida), descuidando los factores contextuales que son centrales para adoptar y sostener estos abordajes.…”

Delivering Advance Care Planning Support at Scale: A Qualitative Interview Study in Twelve International Healthcare Organisations

“…Where they were used, group facilitations were thought a cost-efficient way of extending reach. They were generally run by staff with expertise in this approach, were suitable for all stages of illness and, while rates of document completion were lower than in one-to-one conversations, they could help to prepare people and simplify later conversations and/or decision-making (Lin et al, 2019;Sudore and Fried, 2010). It seems likely there is scope for group approaches to be more widely developed, building on public health approaches to end of life care locally (Karapliagkou and Kellehear, 2013;NHS England/LGA, 2017).…”