Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Effectiveness of advance care planning with family carers in dementia nursing homes: A paired cluster randomized controlled trial”

Brazil K, Carter G, Cardwell C, et al.

Palliative Medicine (2018); 32(3):603–612

DOI: https://doi.org/10.1177/0269216317722413

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Type of Article:

Paired cluster randomised controlled trial

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PICO Analysis:

Population:

• Family carers of nursing home residents with dementia and no decisional capacity
• Residents located in 24 nursing homes in Northern Ireland, all categorised as dementia nursing homes
• Carers were typically daughters (majority female, mean age ~61), and residents had moderately severe to severe dementia

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Intervention:

Structured Advance Care Planning (ACP) intervention, which included:

1. Trained ACP facilitator (a registered nurse with palliative care experience)
2. Family education, including the booklet Comfort Care at the End of Life
3. Two structured family meetings, discussing goals, preferences, values, and symptom management
4. Documentation of the ACP in medical records
5. Orientation of staff and GPs to the ACP process 

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Comparator:

• Usual care, with no structured ACP process, education, or facilitated family meetings

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Outcome:

1. Person-centred outcomes:

• Primary outcome:
  • Decisional Conflict Scale (DCS) – a validated 16-item measure of carer uncertainty in care decision-making
  • Result: Significant reduction in decisional conflict in the intervention group compared to control:
    • Mean difference: –10.5 (95% CI: –16.4 to –4.7; p < 0.001) 
    • Subscales (Informed, Values Clarity, Support, Uncertainty, Effective Decision) all showed significant improvement
• Secondary outcome:
  • Family Perceptions of Care Scale (FPCS) – higher satisfaction in the intervention group, especially in Family Support and Communication subdomains

2. Process outcomes:

• ACP family meetings were completed for 67 of 80 carers in the intervention group
• Meetings lasted ~60 minutes, with 130 minutes average total facilitator time per family (including admin and documentation)
• Carers typically identified goals like:
  • Avoiding unnecessary hospitalisation
  • Comfort-oriented care
  • Discontinuation of non-essential medications
  • Preference to die in the nursing home
  • Desire to be involved in transfer decisions 

3. Health system outcomes:

• Hospitalisations: 7% in the intervention group vs 18% in control
• Hospital deaths: 14% in intervention group vs 20% in control
• Do Not Resuscitate (DNR) orders: 51% in intervention group vs 42% in control
• None of these secondary outcomes reached statistical significance, but all trends favoured the intervention 

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Summary Conclusion:

This paired cluster RCT demonstrated that a structured, nurse-led ACP intervention involving family education, meetings, and documentation significantly reduced carer uncertainty and improved perceptions of care quality in dementia nursing home settings. Although differences in hospitalisations, deaths, and DNR completions were not statistically significant, they trended positively. The intervention was feasible and well-accepted, suggesting that structured ACP with trained facilitation can improve shared decision-making and support family carers in late-stage dementia care.

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