Life In The Slower Lane

Here is the PICO analysis for the eleventh uploaded article:

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✅ PICO Analysis

Full Article Title:

A review of the implementation and research strategies of advance care planning in nursing homes

Type of Study:

Scoping review

Journal and Year:

BMC Geriatrics (2016); 16:24

DOI: 10.1186/s12877-016-0179-4

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P – Population

• Setting: Nursing homes (NHs) internationally
• Participants:
  • NH residents (many with dementia), their relatives, and health personnel (staff, managers, physicians)
• Geographic Distribution: Mostly from English-speaking countries (USA, UK, Canada, Australia, New Zealand, Hong Kong) 

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I – Intervention

• Nature of Intervention:
  • Advance Care Planning (ACP) conversations between patients (or relatives) and health professionals about end-of-life preferences
• Content of Interventions:
  • ACP tools/programs such as:
    • Let Me Decide
    • Let Me Talk
    • POLST (Physician Orders for Life-Sustaining Treatment)
    • Gold Standards Framework for Care Homes (GSFCH)
    • Local or national policy-driven ACP forms
• Implementation Strategies:
  • Education of NH staff (courses, workshops, “train the trainer” models)
  • Use of facilitators
  • Multidisciplinary involvement (nurses, GPs, management)
  • Documentation templates and standardized forms 

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C – Comparison

• Comparator Groups (where applicable):
  • Usual care or pre-intervention baseline
  • Control NHs not receiving ACP education/intervention
  • Retrospective chart data or qualitative interviews from pre-intervention period

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O – Outcomes

1. Implementation Process Outcomes:

• Most studies used education and training as a core implementation tool
• ACP documentation improved when implementation included multidisciplinary teams and consistent leadership
• Staff became more confident in ACP communication in many sites 

2. Health System Outcomes:

• Several studies reported:
  • Fewer hospital admissions and deaths in hospital
  • Better alignment of care with patient wishes
  • Reduced emergency service calls 

3. Documentation and Process Outcomes:

• Increased ACP documentation and formal treatment preferences
• Better palliative care integration in NH routines (e.g., use of GSFCH, LCP)
• High concordance between documented preferences and delivered care (90%+ for POLST forms; lower for feeding tubes)

4. Barriers Identified:

• Non-attendance of physicians
• Legal uncertainties and lack of clarity on surrogates’ roles
• Reluctance among staff, residents, or families to engage in discussions
• Cultural and organisational differences across NHs 

5. Promoters Identified:

• Comprehensive training programmes
• Standardised ACP templates and documentation locations
• Consistent leadership and supportive culture
• Early initiation and repeated follow-up of ACP conversations
• Inclusion of families and consistent GP involvement 

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Outcome Classification

• Person-centred outcomes: Enhanced alignment of care with resident preferences; improved satisfaction for families
• Process outcomes: Increased staff knowledge/confidence, better documentation, and more structured ACP conversations
• Health system outcomes: Fewer hospital transfers, reduced emergency calls, and potential cost savings (reported in other included studies)

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Summary Conclusion

This scoping review highlights the variability, complexity, and often poor reporting of ACP implementation strategies in nursing homes. Despite these challenges, ACP interventions appear to improve documentation, promote preference-aligned care, and reduce unnecessary hospital use—especially when implementation includes staff training, leadership support, and structured processes. However, further high-quality, standardised, and ethically inclusive research—especially involving residents with dementia—is urgently needed .

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