Life In The Slower Lane

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

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Full Title (verbatim and exact):

“Implementing an Advance Care Planning Program in German Nursing Homes: Results of an Inter-Regionally Controlled Intervention Trial”

in der Schmitten J, Lex K, Mellert C, Rothärmel S, Wegscheider K, Marckmann G

Deutsches Ärzteblatt International (2014); 111(4): 50–57

DOI: 10.3238/arztebl.2014.0050

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Type of Article:

Prospective, inter-regionally controlled intervention study (quasi-experimental design)

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PICO Analysis:

Population:

• 575 residents in 13 nursing homes (NHs) in North Rhine–Westphalia, Germany
  • 136 residents in 3 NHs in the intervention region
  • 439 residents in 10 NHs in the control regions
• Participants included both cognitively able and legally represented residents
• Mean age: ~82 years; ~75% female; ~50% with dementia 

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Intervention:

“Beizeiten begleiten®” Advance Care Planning (ACP) program, adapted from Respecting Choices® (USA):

• Facilitator-led ACP discussions for residents and/or proxies (2–5 sessions, ~100 minutes total)
• Standardised, physician-signed documents including:
  • Personal or proxy Advance Directives (ADs)
  • Emergency care orders (HAnNo®, modelled on POLST)
• Staff and community provider training (20 hours for facilitators; 4 hours for GPs)
• Regional coordination across NHs, hospital staff, emergency responders, and GPs 

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Comparator:

• Usual care in 10 NHs in two control towns, without structured ACP intervention or facilitator support
• Residents could still complete ADs independently, but without the structured, facilitated process 

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Outcome:

1. Person-centred outcomes (proxy):

• Not directly measured, but relevant indicators include:
  • Proportion of residents with new ADs
  • ADs with clear resuscitation instructions
  • Physician validation and inclusion of treatment preferences
• In intervention group:
  • 36.0% completed new ADs vs 4.1% in control group (p<0.001)
  • 98% of ADs included emergency care instructions vs 44.4% in control (p<0.01)
  • 93.9% signed by a physician vs 16.7% in control 

2. Process outcomes:

• Designation of proxy in 94.7% of intervention ADs vs 50% in control
• Resuscitation status explicitly defined in 95.9% of ADs in the intervention group
• Eye-catching labels added to files and emergency documents more frequently in intervention group (81.6% vs 0%)
• Only 33% of residents had their AD transferred with them to hospital in both groups, indicating ongoing implementation gaps 

3. Health system outcomes:

• No direct data on hospitalisations or cost
• Time/resource investment:
  • Median of 2.5 ACP conversations per resident
  • ~100 minutes total facilitation time per resident (including preparation and documentation) 
• Authors suggest cost savings likely if future studies confirm reduced hospital use and fewer unwanted interventions

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Summary Conclusion:

This German controlled trial demonstrates that structured ACP programs like “beizeiten begleiten”, when implemented at a regional level with trained facilitators and physician involvement, can dramatically increase both the quantity and quality of advance directives in nursing home residents. The intervention yielded more frequent, physician-validated ADs with clear emergency plans and proxy designations compared to control regions. Despite the time investment, the results support the feasibility and clinical relevance of ACP implementation in German NHs. Further research is warranted to evaluate its impact on hospitalisation rates, healthcare utilisation, and resident preference concordance.

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