Life In The Slower Lane

Here is the PICO analysis for the twenty-sixth uploaded article:

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✅ PICO Analysis

Full Article Title:

Quality of Advance Care Planning Policy and Practice in Residential Aged Care Facilities in Australia

Type of Study:

Pre-implementation survey and document analysis within a broader intervention study (Making Health Choices project)

Journal and Year:

BMJ Supportive & Palliative Care (2013); 3(3):349–357

DOI: 10.1136/bmjspcare-2012-000262

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P – Population

• Setting:
  • 19 Residential Aged Care Facilities (RACFs) across metropolitan and regional Victoria, Australia
• Participants:
  • Staff and management of the RACFs
  • Resident profile data also reviewed (frailty and dementia were the most common reasons for admission)
  • 45 staff members completed the pre-implementation survey 

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I – Intervention

• Nature of Intervention (Planned):
  • Systematic implementation of best practice Advance Care Planning (ACP) via the “Making Health Choices” (MHC) project, informed by the Respecting Patient Choices (RPC) model
  • This article reports only on the pre-implementation evaluation, not outcomes post-intervention
• Components Evaluated:
  • Existing ACP-related policies and procedures
  • Staff understanding, confidence, and behaviour related to ACP
  • Review of existing documentation used to record resident preferences 

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C – Comparison

• Comparator:
  • No formal control group; however, the study compares reported and documented practices against national best practice guidelines
  • Also compares staff self-reported comfort versus actual knowledge and experience as an implicit internal comparison

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O – Outcomes

Key Findings from Pre-Implementation Evaluation:

1. Organisational Policies and Practices

• Only 6 of 12 RACFs had ACP-specific written policies
• No submitted ACP documentation from any facility fully met best practice criteria
• 41% of facilities used a specific ACP form; others used a mix of clinical notes or end-of-life care plans
• Most ACP discussions occurred after admission, often initiated by staff, not residents or families 

2. Staff Knowledge and Behaviour

• Only 25% of staff had conducted ACP discussions with residents in the previous 6 months
• Most felt “comfortable” discussing ACP but reported low levels of skill and confidence
• Over 70% misunderstood key legal aspects of substitute decision-making
• Only 16 of 45 staff (36%) said their facility had ACP policies, and many were unsure if such policies existed 

3. Documentation Issues

• Common issues included:
  • Lack of clarity on resident preferences for hospital transfer
  • Incomplete or vague documentation on specific medical interventions
  • Gaps in nomination of substitute decision makers
  • Lack of routine review or staff training in how to use ACP documents 

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Outcome Classification

• Person-centred outcomes:
  • Not directly measured; however, the study highlights inconsistencies in capturing and honouring resident wishes at end of life
• Process outcomes:
  • Evaluation of ACP uptake, policy presence, documentation practices, and staff capabilities highlights systemic gaps in implementation
• Health system outcomes:
  • Not formally evaluated in this phase, but downstream implications include potential for preventable transfers, misaligned care, and distress due to unrecognised ACP preferences

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Summary Conclusion

This pre-implementation evaluation of 19 Australian RACFs found that while some ACP activity was occurring, practices were inconsistent, underdeveloped, and poorly aligned with best practice guidelines. Staff generally supported ACP in principle but reported low confidence, skill, and understanding of legal roles and procedures. Documentation tools were inadequate, and ACP was often poorly integrated into routine care. The findings justify a structured, whole-of-organisation approach to ACP implementation with attention to education, systems, and legal literacy in aged care settings .

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