Life In The Slower Lane

Here is the structured PICO analysis for the twenty-first article you uploaded:

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Full Title (verbatim and exact):

“BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial”

Garland A, Keller H, Quail P, et al.

Age and Ageing (2022); 51(3):afac049

DOI: https://doi.org/10.1093/ageing/afac049

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Type of Article:

Cluster randomised controlled trial (RCT)

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PICO Analysis:

Population:

• Nursing home residents aged ≥65 years in 29 nursing homes across three Canadian provinces (Ontario, Manitoba, Alberta)
• Participants were frail and at elevated risk of death within 6–12 months (based on predefined risk criteria)
• Total enrolled: 713 residents (442 control, 271 intervention) 

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Intervention:

• The BABEL (Better tArgeting, Better outcomes for frail ELderly patients) ACP approach—a comprehensive, structured, person-centred ACP intervention, including:
  • A 60-minute structured ACP discussion between resident, substitute decision-maker (SDM), and nursing home staff
  • Components:
    • SDM identification and clarification of roles
    • Resident clinical condition explanation
    • Preferred decision-making philosophy
    • Specific care preferences for anticipated medical emergencies
  • Training and tools for staff and stakeholders
  • Annual or event-triggered repeat discussions

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Comparator:

• Usual care: Standard ACP practices already in place in control homes (unstructured and often lacking full documentation or physician participation) 

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Outcome:

1. Person-centred outcomes:

• Primary outcome 1:
  • Comprehensiveness of ACP (Audit of ACP score, scale 0–7):
    • Significantly improved in the intervention group (OR = 5.21, 95% CI 3.53–7.61, P < 0.001 after adjustment)
• Primary outcome 2:
  • Comfort in dying (Comfort Assessment in Dying scale):
    • No significant difference between groups
• Secondary outcomes (person-focused):
  • Resident self-efficacy in ACP: No significant difference
  • SDM satisfaction with end-of-life care: No significant difference
  • SDM perception that the plan of care was followed: No significant difference
  • Discordance between preferences and care received: very low (2 of 214 cases) 

2. Process outcomes:

• ACP discussions were more comprehensive and consistently documented
• Qualitative data showed improved staff confidence and communication regarding ACP
• However, only 18.7% of BABEL discussions included a physician, indicating room for improvement in interdisciplinary engagement

3. Health system outcomes:

• Antimicrobial use: Significantly reduced in intervention homes (IRR = 0.79, P = 0.048 after adjustment)
• No significant differences in:
  • Hospital/emergency transfers (though IRR = 0.77 showed a non-significant trend)
  • ICU admissions
  • Other therapeutic or diagnostic interventions
  • Mortality or palliative care entry rates 

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Summary Conclusion:

This large Canadian cluster RCT evaluated the BABEL ACP approach—a structured, person-centred, and evidence-informed ACP model for frail older residents in nursing homes. It resulted in significantly greater ACP comprehensiveness and a reduction in antimicrobial use, suggesting that well-conducted ACP may reduce unnecessary interventions. However, it did not affect comfort in dying or hospitalisation rates, possibly due to high baseline quality of end-of-life care and insufficient power. Implementation challenges (e.g., time, physician engagement) were noted, reinforcing the need for system-level changes and resourcing to embed comprehensive ACP in routine nursing home practice.

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