A Systematic Review of the Effects of Advance Care Planning Interventions in Nursing Homes

Background: Advance care planning (ACP) interventions are implemented to achieve outcomes such as improving end-of-life care and increasing goal-concordant care. ACP has been studied across various settings, but it is important to study the impacts of ACP in nursing homes. Objective: To review and evaluate the outcomes of ACP interventions in nursing homes. Design: Systematic review of randomized controlled trials. Methods: A search was last performed on March 27, 2023, using MEDLINE, Embase, CINAHL Complete, Cochrane Library, and clinicaltrials.gov. Eligible studies were randomized controlled trials that studied the impact of ACP interventions in nursing homes with residents over the age of 18. The Cochrane Risk of Bias tool 2.0 was used to determine the studies’ risk of bias. The ACP Outcomes Framework was utilized to organize the results into 5 domains: Process, Action, Quality of Care, Health Status, and Health Care Utilization. No meta-analysis was possible because of heterogeneity in study interventions and outcomes. Results: Twenty-three studies met criteria for inclusion in this review. Most studies were at low or medium risk of bias. The study interventions included resident and family education, staff education, structured discussions, communication with primary medical teams, and use of specialists. A slight majority of Action and Process outcomes were positive, whereas Quality of Care outcomes were mixed. A minority of Health Care Utilization and Health Status outcomes were positive. Multi-component interventions and interventions featuring staff education were often successful. Conclusions: ACP interventions in nursing homes yield beneficial outcomes in some domains. Limitations to this review include the presence of heterogeneity in types of study interventions and outcomes, as well as underpowering of many study outcomes. Further work is needed to improve ACP implementation, identify which interventions are most beneficial, and ensure sustainability of beneficial interventions.

Duke Scholars

Author Collin Elizabeth Burks Medicine, Geriatrics and Palliative Care

Author Sarah Cantrell  

Author Mamata Yanamadala Medicine, Geriatrics and Palliative Care