Life In The Slower Lane

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

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Full Title (verbatim and exact):

“An Interim Analysis of an Advance Care Planning Intervention in the Nursing Home Setting”

Hickman SE, Unroe KT, Ersek MT, et al.

Journal of the American Geriatrics Society (2016); 64(11):2385–2392

DOI: 10.1111/jgs.14463

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Type of Article:

Interim implementation study of a multicomponent intervention within a broader demonstration project (OPTIMISTIC)

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PICO Analysis:

Population:

• 2,709 long-stay residents of 19 nursing homes in Indiana, USA
• All had been enrolled in the CMS-funded OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality and Improving Symptoms: Transforming Institutional Care) project for at least 30 days between August 2013 and December 2014
• Primarily older adults, with high rates of dementia, multimorbidity, and functional impairment 

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Intervention:

Structured Advance Care Planning (ACP) led by specially trained OPTIMISTIC RNs, including:

• Use of Respecting Choices Last Steps ACP model
• Collaborative ACP discussions with residents and/or legal representatives
• Resulting documentation such as:
  • Physician Orders for Scope of Treatment (POST) (Indiana’s version of POLST)
  • DNR and other treatment limitation orders
• Implementation included:
  • Comprehensive training of RNs
  • Integration of ACP into broader clinical review and care transitions
  • Facility engagement and protocol development 

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Comparator:

• No randomised comparator group
• Compared residents with and without documented ACP conversations by OPTIMISTIC RNs
• Also analysed barriers to implementation and baseline vs. updated treatment preferences

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Outcome:

1. Person-centred outcomes (proxy):

• Of residents with ACP conversations:
  • 69% had a documented change in treatment preferences
  • 87% of changes involved completion of a new POST form
  • 55% of POST forms selected comfort care only (Section B)
  • Residents who had ACP discussions were more likely to be enrolled in hospice or have limited prognosis (life expectancy <6 months) 

2. Process outcomes:

• Only 27% of residents had ACP conversations facilitated by project nurses at 17 months
• Barriers included:
  • Competing time demands (reported in 57.6% of missed cases)
  • Lack of decision-making capacity and no legal representative (20.9%)
  • Scheduling difficulties and resident/family unreadiness
• Conversations averaged 39.6 minutes, and many residents required more than one conversation (up to 7)
• The audit revealed that 42% of residents had ACP documented in their charts—30% by other facility staff 

3. Health system outcomes:

• Not directly assessed in this interim analysis, but the broader OPTIMISTIC project aimed to reduce avoidable hospitalisations
• Future analyses were planned to link ACP implementation with hospitalisation and ED visit rates
• Barriers to scale-up include need for dedicated staff, system-wide education, and policy alignment to support ACP as routine care 

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Summary Conclusion:

This interim analysis from the OPTIMISTIC demonstration project shows that structured, nurse-led ACP in nursing homes is feasible but requires significant time, training, and support. ACP conversations led to meaningful changes in documented preferences in two-thirds of cases, especially through the use of POST forms. However, uptake was limited by competing demands, resident turnover, and staffing constraints. The findings support investment in system-level ACP strategies—including skilled facilitators and integrated documentation systems—to improve alignment between treatment and resident goals, reduce unwanted hospitalisations, and ensure high-quality end-of-life care in long-term care settings.

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