Here is the structured PICO analysis for the forty-seventh article you uploaded:
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Full Title (verbatim and exact):
“Implementing advance care planning in nursing homes – study protocol of a cluster-randomized clinical trial”
Sævareid TJL, Lillemoen L, Thoresen L, Førde R, Gjerberg E, Pedersen R
BMC Geriatrics (2018); 18:180
DOI: https://doi.org/10.1186/s12877-018-0869-1
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Type of Article:
Study protocol for a cluster-randomised clinical trial with mixed methods evaluation
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PICO Analysis:
Population:
- Residents of Norwegian nursing homes (NHs)
- 8 NH wards from 8 facilities, cluster-randomised
- Inclusion:
- Aged ≥70 years
- Residing ≥3 months in NH
- Exclusion: inability to speak or understand Norwegian
- Characteristics of typical residents:
- Mean age: ~84 years
- High dependency and complex needs
- ~80% have cognitive impairments or dementia
Intervention:
A 12-month, multifaceted implementation of a structured ACP guideline, including:
- A national ACP guideline emphasising:
- Voluntary, inclusive ACP conversations
- Decision-making capacity (DMC) assessment
- Inclusion of patients with and without DMC
- Questions about life values, goals, and treatment preferences
- Train-the-trainer model:
- Local project teams (nurse, physician, manager) received 2-day seminars
- These teams delivered training and supervised implementation
- Tools:
- Pocket cards and documentation templates
- Conversation invitations
- Posters and folders for staff, patients, and next of kin (NOK)
- Observation logs and coordinator logs to support fidelity
Comparator:
- Usual care (no systematic ACP implementation) in matched control NH wards
- Control facilities received a single-day seminar post-trial
Outcome:
1. Person-centred outcomes:
- Primary outcome:
- Documentation of a conversation about end-of-life treatment with the patient or NOK
- Secondary outcomes:
- Documentation of patients’:
- Hopes and worries for the future
- Wishes for proxy decision-makers
- Preferences on life-prolonging treatment and hospitalisation
- Concordance between documented wishes and treatment received
- Inclusion of patients with cognitive impairment in ACP
- Competence to consent assessments
- Documentation of patients’:
2. Process outcomes:
- Fidelity and feasibility measured via:
- Qualitative logs and focus groups with staff
- Observations of ACP conversations
- Interviews with patients, NOK, and healthcare staff
- Assessed:
- Barriers/facilitators to implementation
- Experiences of the conversations
- How ACP conversations were documented and acted upon
3. Health system outcomes (proxy):
- Not directly measured, but implied goals:
- More appropriate hospitalisation decisions
- Better-informed care aligned with resident preferences
- Reduced decisional burden on NOK
- Cultural shift toward shared decision-making in NHs
Summary Conclusion:
This protocol describes a robust, theory-informed trial to implement ACP in Norwegian nursing homes using a cluster-randomised design and a train-the-trainer model. The intervention supports inclusive, values-based conversations—even for people with reduced DMC—and provides structured tools and staff training. The primary outcome focuses on whether ACP is documented, while the mixed-methods design explores experiential, clinical, and implementation factors. If effective, this trial could inform nationwide strategies for embedding ACP into routine practice across aged care systems.
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