Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

A complex regional intervention to implement advance care planning in one town’s nursing homes: Protocol of a controlled inter-regional study

Authors: in der Schmitten J, Rothärmel S, Mellert C, et al.

Journal: BMC Health Services Research (2011); 11:14

DOI: 10.1186/1472-6963-11-14

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✅ PICO Analysis

Type of Study:

Controlled inter-regional, longitudinal implementation study (study protocol)

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P – Population

• Setting:14 nursing homes (NHs) across three German towns:
  • Intervention group: 4 NHs (n = 421 residents)
  • Control groups: 10 NHs (n = 985 residents)
• Participants:
  • All residents of participating nursing homes were eligible
  • 645 residents (41%) provided informed consent
    • 38% participation in intervention region
    • 42% in control region
• Resident Characteristics (from non-responder analysis):
  • Similar age and sex distribution between responders and non-responders
  • Higher representation of residents with high-level care dependency (Category III) among participants

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I – Intervention

• Multifaceted Regional Advance Care Planning (ACP) ProgrammeAdapted from the U.S.-based Respecting Choices® model
• Key Components:
  1. Facilitator Training:
     • 16 social workers/nurses trained in a 5-day ACP facilitation course
     • Ongoing plenary sessions to support practice
  2. GP Engagement and Training:
     • 20 GPs trained (caring for >85% of residents)
     • Involved in attesting capacity and co-signing ACP documents
  3. Systemic Integration:
     • Collaboration with local hospitals, emergency services, and district government
     • Implementation of structured documentation and interface tools (e.g. POLST-E forms)
  4. Tools Developed:
     • Patient and Proxy Advance Directives (ADs)
     • Physician Orders for Life-Sustaining Treatment – Emergency (POLST-E)
     • Guides and policies for conversation, documentation, transfer, and access
• No financial incentive provided to facilities or staff beyond free training

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C – Comparison

• Control Group:
  • 10 NHs in two demographically similar towns
  • Usual care with no structured ACP intervention
  • No training or formal ACP tools offered
  • Residents and staff aware only of general observational research aims

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O – Outcomes

Primary Outcome:

1. Prevalence of Advance Directives (ADs):
   • Measured after intervention period
   • Distinguishes between patient-signed ADs and proxy ADs

Secondary Outcomes:

Process Quality Indicators:

• Relevance and validity of ADs (e.g. signatures, clarity, emergency use)
• Accessibility of ADs in nursing home and hospital files
• Transfer of ACP documents across care settings

Clinical Outcome Indicators:

• Rates of:
  • CPR, feeding tube placement, intubation, dialysis, endoscopy, imaging
  • Hospital transfers (all, non-surgical, and ICU)
• Location of death (home vs hospital)
• Treatments before death compared to preferences

Satisfaction and Alignment:

• Proxy, resident, and caregiver satisfaction with ACP process
• Concordance of documented preferences with actual care

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Outcome Classification

• Person-Centred Outcomes:
  • Documented treatment preferences (ADs)
  • Place of death
  • Burden of life-sustaining interventions
  • Satisfaction with care process
• Process Outcomes:
  • Rates of completed ADs
  • Validity and accessibility of ACP documents
  • Transfer and availability of ACP across settings
  • Quality of communication and documentation
• Health System Outcomes:
  • Hospitalisation and intervention rates
  • Use of emergency services
  • Potential reductions in unwanted interventions and increased goal-concordant care

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