Life In The Slower Lane

Here is the PICO analysis for the tenth uploaded article:

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✅ PICO Analysis

Full Article Title:

The Effects of Advance Care Planning Interventions on Nursing Home Residents: A Systematic Review

Type of Study:

Systematic review

Journal and Year:

Journal of the American Medical Directors Association (JAMDA), 2016; 17(4):284–293

DOI: 10.1016/j.jamda.2015.12.017

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P – Population

• Setting: Nursing homes (also referred to as residential aged care facilities, long-term care units, or skilled nursing facilities)
• Participants:
  • Frail older adults residing in nursing homes internationally
  • Most participants had cognitive impairments or chronic, life-limiting illnesses such as dementia
• Geographic Spread: 13 studies from the USA, Canada, Australia, Hong Kong, Singapore, UK, and the Netherlands 

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I – Intervention

• Nature of Interventions:
  • Advance care planning (ACP) interventions, including:
    1. Educational programs (staff, residents, and families)
    2. Introduction or evaluation of ACP forms (including POLST)
    3. Combined ACP + palliative care initiatives
    4. Use of medical treatment orders (e.g. DNR/DNH)
• Examples:
  • “Let Me Decide” and “Let Me Talk” ACP tools
  • Implementation of POLST forms
  • Staff training programs
  • Structured ACP interviews and documentation protocols 

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C – Comparison

• Comparators Across Studies:
  • Control groups with usual care
  • Pre-post comparisons within the same facility
  • Matched controls without ACP interventions
  • No comparator in some prospective cohort studies (observational comparison)

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O – Outcomes

Primary Outcomes Identified in the Review:

1. Hospitalisation:
   • ACP reduced hospitalisation by 9% to 26%
   • In two studies, reduced hospitalisation did not lead to increased mortality 
2. Place of Death:
   • ACP increased in-place (nursing home) deaths by 29–40%
   • Residents more likely to die in their preferred place of death 
3. Consistency with Residents’ Wishes:
   • ACP improved treatment concordance with resident preferences
   • Effectiveness varied by directive type (e.g. resuscitation preferences followed more consistently than antibiotic preferences)
4. Use of Life-Sustaining Treatments:
   • ACP was associated with decreased use of interventions such as CPR, hospital transfers, and tube feeding 
5. Healthcare Costs:
   • Two studies showed significantly reduced hospital costs and total health expenditures among ACP groups
6. Quality of Life (QOL) and Family Satisfaction:
   • One study showed significant improvements in QOL, reduced physical discomfort, and existential distress
   • Another found increased family satisfaction when comfort goals were explicitly established 
7. Mortality:
   • ACP was not associated with increased mortality; in some cases, it was associated with stable or improved survival despite reduced hospitalisation
8. Palliative Care/Hospice Referrals:
   • One study showed increased referrals to community palliative care; hospice referrals were unchanged 

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Outcome Classification

• Person-centred outcomes: Higher rates of preference-concordant care; increased QOL; improved satisfaction
• Process outcomes: Increased documentation of preferences; improved staff-family communication
• Health system outcomes: Reduced hospitalisation, reduced healthcare costs, increased in-facility death aligned with wishes

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Summary Conclusion

Advance care planning interventions demonstrate beneficial outcomes for nursing home residents, including reduced hospitalisation, increased concordance with preferences, and cost savings. However, the overall quality of the evidence was low, with few high-quality randomised controlled trials. Most studies were educational or focused on implementing ACP forms like POLST. Authors call for more rigorous studies to determine which ACP models are most effective in nursing home settings .

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