Life In The Slower Lane

Here is the structured PICO analysis for the forty-ninth article you uploaded:

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Full Title (verbatim and exact):

“An Advance Care Planning Video Decision Support Tool for Nursing Home Residents With Advanced Dementia: A Cluster Randomized Clinical Trial”

Mitchell SL, Shaffer ML, Cohen S, et al.

JAMA Internal Medicine (2018); 178(7):961–969

DOI: https://doi.org/10.1001/jamainternmed.2018.1506

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Type of Article:

Cluster randomized controlled trial (EVINCE trial)

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PICO Analysis:

Population:

• 402 residents with advanced dementia and their proxies in 64 nursing homes around Boston, USA
• Inclusion:
  • Age ≥65 years
  • Global Deterioration Scale (GDS) stage 7
  • Proxy available for participation
• Mean age: 86.7 years; 80% female; 87% white
• Proxies: Mostly adult children, average age ~62 years 

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Intervention:

• A 12-minute advance care planning (ACP) video shown to proxies describing:
  • Typical features of advanced dementia
  • Treatment options: intensive, basic, and comfort care
  • Realistic visuals (e.g. feeding tubes, personal care, oxygen therapy)
• Proxies’ post-video care preferences were documented and sent to the clinical care team
• The video aimed to improve alignment between preferences and advance directives

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Comparator:

• Usual care: Verbal descriptions of care levels provided to proxies
• No video shown; preferences not systematically communicated to clinicians 

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Outcome:

1. Person-centred outcomes:

• Proxies’ preferred level of care:
  • No difference in preference for comfort care between arms at any time point
  • ~65% of proxies chose comfort care at baseline in both arms 

2. Process outcomes:

• Primary outcome:
  • Proportion with do-not-hospitalize (DNH) directives by 6 months
  • No significant difference: 63% in both arms (AOR 1.08; 95% CI 0.69–1.69) 
• Secondary outcomes:
  • Tube-feeding directives: significantly more frequent in intervention arm at all time points (AOR range 1.78–2.32)
  • Goals-of-care discussions: more common at 3 months in intervention arm (AOR 2.58; 95% CI 1.20–5.54), but not at later times
  • Intravenous hydration directives: no significant difference 
• Exploratory outcome:
  • Among proxies who preferred comfort care, residents in the intervention arm were significantly more likely to have both DNH and no tube-feeding directives (AOR 2.68; 95% CI 2.68–5.85) 

3. Health system outcomes:

• Burdensome treatments (hospital transfer, feeding tubes, parenteral therapy):
  • Low across both arms and did not differ significantly
  • Mean ~1.2–1.4 interventions per 1000 resident-days 

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Summary Conclusion:

The EVINCE trial found that an ACP video for proxies of nursing home residents with advanced dementia did not increase DNH orders, reduce burdensome treatments, or shift care preferences, but did increase documentation of tube-feeding restrictions and, temporarily, goals-of-care discussions. When proxies preferred comfort care, those in the intervention group were more likely to have aligned advance directives. The intervention may be more effective if implemented earlier in the disease course or integrated into broader care processes. The study highlights that preferences alone are insufficient to drive changes in treatment unless systems support documentation and implementation.

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