Here is the standardised PICO analysis for the sixteenth uploaded article:
Full Title
A Systematic Review of the Effects of Advance Care Planning Interventions in Nursing Homes
Authors: Collin E. Burks, Omid Salaami, Sarah E. Cantrell, Neema K. Sharda, Mamata Yanamadala
Journal: Journal of the American Medical Directors Association (JAMDA), 2023; 24(10):1809–1819
DOI: 10.1016/j.jamda.2023.09.018
Type of Study
Systematic review of 23 randomised controlled trials (RCTs) on advance care planning (ACP) in nursing homes
PICO Summary
Population (P)
- Residents of nursing homes (including both long-stay and short-stay populations)
- Studies from USA, Europe, Australia, Canada, and China
- Some studies included residents with advanced illness or cognitive impairment, including dementia
Intervention (I)
- Advance Care Planning (ACP) interventions, including:
- Resident and family education (e.g. video decision aids)
- Staff education and training programs
- Structured discussions (e.g. facilitated family meetings)
- Communication with primary medical teams
- Utilisation of specialist palliative care input
- Delivered via single or multi-component strategies at resident, staff, or facility levels
Comparison (C)
- Standard care or alternative non-ACP interventions
- Comparator arms varied across trials (usual care, education only, or non-specialist discussions)
Outcomes (O)
Outcomes were classified using the ACP Outcomes Framework into 5 domains:
1. Process Outcomes
- Knowledge, self-efficacy, and attitudes:
- Slightly more than half showed positive changes (e.g. increased staff knowledge, improved attitudes towards shared decision-making)
2. Action Outcomes
- Documentation and decision-making behaviours:
- Majority of studies showed increased ACP documentation, DNR/MOST/MOLST orders, and goal discussions
- Evidence for changes in actual care preferences was mixed
3. Quality of Care Outcomes
- Mixed findings overall:
- Reduced decisional conflict in 3 studies
- Improved communication quality (staff and family reports) in 3 studies
- Improved satisfaction with care and perceived care concordance in a few studies
4. Health Status Outcomes
- No significant differences found in:
- Mortality
- Quality of life
- Caregiver burden or distress
5. Health Care Utilisation Outcomes
- Mixed but promising findings:
- 4 of 13 studies showed reduced hospitalisations or emergency transfers
- 2 of 3 studies showed reduced hospital-related costs (e.g. Molloy et al: 33% lower per-resident hospital costs)
- Hospice uptake increased in only 1 of 5 studies
Findings Summary
- ACP interventions in nursing homes can lead to meaningful changes in documentation, decision-making, communication, and reducing decisional conflict
- Less consistent impact on hospital use, quality of life, or mortality
- Multi-component interventions, especially those including staff education, were more likely to yield positive outcomes
- Many studies were underpowered or limited by implementation fidelity, and varied in structure and outcome focus
Life In The Slower Lane 
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