Life In The Slower Lane

Here is the structured PICO analysis for the seventeenth article you uploaded:

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Full Title (verbatim and exact):

“Change in Advance Care Plans of Nursing Home Residents With Dementia and Pneumonia: Secondary Analysis of Randomized Controlled Trial Data”

Bavelaar L, Visser M, Schlicksupp P, Tilburgs B, van der Maaden T, Achterberg WP, van der Steen JT

Journal of the American Medical Directors Association (2022); 23(10):1741.e19–1741.e26

DOI: https://doi.org/10.1016/j.jamda.2022.06.024

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Type of Article:

Secondary analysis of a cluster-randomised controlled trial (PneuMonitor trial)

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PICO Analysis:

Population:

• Nursing home residents with dementia in 32 public, non-profit nursing homes across the Netherlands
• Total sample: 429 residents with pneumonia episodes between 2012 and 2015
• Most residents had severe dementia (45%) and were aged around 85 years 

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Intervention:

• Episode of pneumonia as a natural event triggering potential reassessment of advance care plans
• Focused on examining changes in:
  • Prioritised treatment goals (e.g. comfort vs life prolongation)
  • Advance treatment decisions (e.g. resuscitation, hospitalisation, antibiotics, artificial hydration)

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Comparator:

• Status of advance care plans before pneumonia diagnosis
• All participants served as their own comparators in a pre–post analysis

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Outcome:

1. Person-centred outcomes:

• Changes in advance care plans after pneumonia:
  • Treatment goals changed in 15.9% of residents
  • Advance treatment decisions changed in 20% of residents
  • Most changes were refinements rather than reversals (e.g. do to do-not orders)
• The majority of residents had a care plan favouring comfort-focused care even before pneumonia (61.8%) 

2. Process outcomes:

• Physicians identified family members as the most influential in shared decision-making (47.4%)
• ACP with the resident themselves was rare (only 10.3% were considered most influential)
• Severe illness (OR 1.5) and terminal prognosis (OR 3.3) were associated with increased likelihood of changing treatment decisions, but not treatment goals 

3. Health system outcomes:

• The study did not directly evaluate resource use or costs but noted that hospitalisation was rare in this cohort (1%) and most decisions were for symptom control, not life prolongation
• Artificial nutrition and hydration were less frequently discussed before pneumonia but increased slightly after the event (e.g. hypodermoclysis orders rose by 5.1%) 

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Summary Conclusion:

This study highlights that while advance care plans were well established among Dutch nursing home residents with dementia, changes in these plans following a pneumonia diagnosis were relatively rare. When changes occurred, they were more often adjustments in treatment decisions—not shifts in underlying care goals. Severe illness and a short prognosis were key triggers for reassessment. Importantly, ACP conversations with the residents themselves were uncommon, reinforcing the need for improved practices around including people with dementia in their own care planning while they retain decision-making capacity.

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