Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Implementation of ‘Goals of Patient Care’ medical treatment orders in residential aged care facilities: protocol for a randomised controlled trial”

Martin RS, Hayes BJ, Hutchinson A, et al.

BMJ Open (2017); 7:e013909

DOI: 10.1136/bmjopen-2016-013909

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Type of Article:

Protocol for a cluster-randomised controlled trial using mixed methods (quantitative and qualitative)

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PICO Analysis:

Population:

• Residents of six residential aged care facilities (RACFs) in Victoria, Australia
• Participants include those with and without existing advance care plans; substitute decision-makers (SDMs) also involved
• Residents with dementia and other life-limiting illnesses included, unless no SDM is available for those lacking capacity 

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Intervention:

Goals of Patient Care (GOPC) medical treatment orders—a structured medical treatment order completed by a physician in collaboration with the resident and/or SDM. The GOPC:

• Converts prior advance care plans into actionable medical orders
• Categorises treatment preferences into four main goals (A–D):
  • A: Full active treatment (including CPR and hospital transfer)
  • B: Limited active treatment (no CPR or intubation)
  • C1–C3: Treatment only if non-burdensome, with subcategories for trial of treatment, treatment in RACF only, or symptom management only
  • D: End-of-life care only (terminal phase) 

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Comparator:

• Usual care, including existing advance care planning processes without a structured medical treatment order
• Some residents may already have ACPs in place, but these vary widely in quality and clarity; no site used medical treatment orders before the study 

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Outcome:

1. Person-centred outcomes:

• Not directly measured, but secondary outcomes include:
  • Place of death
  • Whether the GOPC clarified and improved alignment of treatment decisions with resident wishes
  • Staff and SDM views on communication and conflict reduction 

2. Process outcomes:

• Primary outcome:
  • 40% reduction in emergency department (ED) attendances and hospital admissions at 6 months in intervention vs. control facilities 
• Secondary outcomes:
  • ED visits, hospital admissions, and acute length of stay at 3 and 12 months
  • Uptake and change rate of GOPC forms
  • Staff-reported changes in:
    • Decision-making confidence
    • Communication clarity
    • Conflict around deterioration events
  • Staff and GP experiences gathered via qualitative interviews and focus groups 

3. Health system outcomes:

• Healthcare utilisation metrics (collected via local hospital databases):
  • ED attendance rates
  • Admissions
  • Length of stay
  • Associated acute care costs
  • Ambulatory care service use (inreach geriatrician reviews)
• Mortality rates and place of death also recorded at 12 months 

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Summary Conclusion:

This trial protocol aims to assess whether implementing a structured, physician-completed Goals of Patient Care (GOPC) form—integrating clinical judgment with patient/SDM preferences—can reduce unnecessary hospitalisations and improve clarity of care decisions during deterioration in RACFs. The trial uses a robust cluster-randomised design, with mixed methods to evaluate both impact and implementation. This is the first RCT of its kind examining the GOPC form in RACFs, and its findings could inform policy on scalable models of advance care planning in aged care settings.

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