Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Concordance between Goals of Care and Treatment Decisions for Persons with Dementia”

Ernecoff NC, Zimmerman S, Mitchell SL, et al.

Journal of Palliative Medicine (2018); 21(10):1442–1447

DOI: https://doi.org/10.1089/jpm.2018.0103

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Type of Article:

Secondary analysis of a cluster-randomised trial (GOC trial)

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PICO Analysis:

Population:

• 302 dyads of residents with late-stage dementia and their family decision makers
• All residents were aged ≥65, resided in 22 North Carolina nursing homes, and had Global Deterioration Scale (GDS) stage 5–7 dementia
• Family served as surrogate decision-makers; majority were adult children
• Residents: 82% female, mean age 87
• Family decision makers: 68% female, mean age 63 

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Intervention:

• Family decision makers selecting a primary goal of care (GOC):
  • Comfort (66% at baseline, 80% at follow-up)
  • Supporting function
  • Prolonging life
• The original GOC trial included a video decision aid intervention, but this analysis focused on the association between GOC and treatment decisions

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Comparator:

• Comparison between residents whose family decision maker selected comfort as the primary GOC versus other goals (supporting function, prolonging life, or multiple/unspecified goals) 

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Outcome:

1. Person-centred outcomes:

• Perceived goal-concordant care:
  • 49% of families perceived staff aligned with their GOC at baseline
  • 69% perceived concordance at follow-up (p < 0.001)
• Only 3% of families reported receiving care inconsistent with the resident’s stated preferences (as per ACP problem score) 

2. Process outcomes:

• Orders and documentation:
  • No significant difference in DNR, do-not-hospitalize, or hospice enrollment based on comfort goal at baseline
  • Only 18% of residents with a comfort goal had a MOST (Medical Orders for Scope of Treatment) form documenting comfort as the directive
• ACP problem score indicated substantial room for improvement in discussions and planning:
  • Only 40% of families reported being spoken to about the resident’s treatment wishes in the past 3 months 

3. Health system outcomes:

• Hospital transfers:
  • Residents with a comfort goal had half as many hospital transfers (0.11 vs 0.25 per 90 person-days; β = –0.1; 95% CI –0.2 to –0.01; p < 0.05)
• No significant differences were found in:
  • Hospice enrollment
  • Use of antibiotics, tube feeding, or treatment plans for symptom management
  • Palliative Care Domain Scores (mean ~6.1 in both groups on 0–10 scale) 

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Summary Conclusion:

In this analysis of the GOC trial, most families of nursing home residents with late-stage dementia chose comfort as the primary goal of care, yet actual treatment decisions and documentation did not consistently reflect this preference. Selecting comfort as the goal was associated with fewer hospital transfers, but not with greater hospice use, better symptom management, or documented treatment limitations. Only half of families perceived alignment between their goals and NH treatment plans. The findings highlight a gap between stated goals and clinical practice, indicating the need for improved communication, documentation, and implementation strategies to honour person-centred preferences in advanced dementia care.

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