Here is the PICO analysis for the twenty-second uploaded article:
✅ PICO Analysis
Full Article Title:
Implementing an Advance Care Planning Program in German Nursing Homes: Results of an Inter-Regionally Controlled Intervention Trial
Type of Study:
Prospective, inter-regionally controlled, non-randomised intervention trial
Journal and Year:
Deutsches Ärzteblatt International (2014); 111(4): 50–57
DOI: 10.3238/arztebl.2014.0050
P – Population
- Setting:
- 13 nursing homes in North Rhine–Westphalia, Germany
- 3 in the intervention region
- 10 in two matched control regions
- 13 nursing homes in North Rhine–Westphalia, Germany
- Participants:
- 575 residents in the per-protocol analysis (136 intervention; 439 control)
- Inclusion: all residents or new admissions during the 16.5-month study
- Approximately 50% had dementia; ~25% at highest nursing care level
I – Intervention
- Intervention Name: “beizeiten begleiten” (German ACP program)
- Components (adapted from the US “Respecting Choices®” model):
- 20-hour training for facilitators (nursing home staff and hospice volunteers)
- 4-hour training for participating primary care physicians
- Region-wide educational outreach to emergency services, hospital staff, guardianship services
- Use of tailored standardised forms:
- Personal and proxy advance directives (ADs)
- Physician-signed emergency care orders (HAnNo® – adapted from POLST)
- Professional, structured facilitation involving residents and families:
- ≥2 structured ACP conversations per participant
- Optional completion of written ADs, physician validation, and file archiving
C – Comparison
- Control Condition:
- 10 nursing homes in other regions received no intervention
- Residents could still complete ADs on their own, but no structured program or training was offered
O – Outcomes
Primary Outcome:
- Incidence of new advance directives (ADs) during the 16.5-month intervention:
- 36.0% in intervention vs. 4.1% in control region (p < 0.001)
Secondary Outcomes:
Validity and Relevance of New ADs (Table 2):
- Physician signature: 93.9% vs. 16.7%
- POLST-like emergency order included: 98.0% vs. 44.4%
- Resuscitation preference clearly documented: 95.9% vs. 38.9%
- Proxy designation: 94.7% vs. 50.0%
Prevalence of All ADs at End of Study (Table 3):
- Any AD: 52.2% vs. 24.8%
- Validity indicators (e.g. physician signature, clarity, documentation in file) significantly higher in intervention group
Process Measures:
- Median time for facilitation: 100 minutes (range 60–240), across median 2.5 sessions
- Facilitators helped develop and document residents’ preferences; validated by primary care physician
Outcome Classification
- Person-centred outcomes:
- Increased completion of meaningful, personalised ADs
- Enhanced clarity of preferences and inclusion of emergency care orders
- Process outcomes:
- Establishment of a structured ACP facilitation model
- Improved documentation and communication across sectors (hospital, emergency care, nursing home)
- System-level outcomes:
- No data on hospitalisation reduction or cost-effectiveness in this paper, but the model aligned with other ACP systems that report such benefits (e.g., La Crosse, Wisconsin; Canada; Australia)
Summary Conclusion
This prospective controlled trial demonstrates the feasibility and success of implementing a structured, regionally supported Advance Care Planning (ACP) program—beizeiten begleiten®—in German nursing homes. The intervention resulted in a ninefold increase in new ADs, most of which met high standards of validity, clarity, and emergency applicability. Professional facilitation, integration with primary care and emergency systems, and standardised forms were key components. While downstream clinical and economic outcomes were not evaluated, the program establishes a high-quality ACP framework that warrants broader implementation and further evaluation .
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