Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

Facilitators and barriers to advance care planning implementation in Australian aged care settings: A systematic review and thematic analysis

Authors: Frances Batchelor, Kerry Hwang, Betty Haralambous, et al.

Journal: Australasian Journal on Ageing (2019); 38(3):173–181

DOI: 10.1111/ajag.12639

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✅ PICO Analysis

Type of Study:

Systematic review and thematic analysis

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P – Population

• Setting:Australian residential aged care facilities (RACFs) and community aged care services
• Participants:
  • Residents of aged care
  • Family members and substitute decision-makers
  • Aged care staff, case managers, general practitioners, and organisational managers
  • 9 studies included: 7 qualitative studies and 2 intervention studies, with varying perspectives (nurses, managers, older adults, and families)

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I – Intervention

• Advance Care Planning (ACP) implementation strategies in aged care settings, such as:
  • Structured staff training and education
  • Use of standardised forms and documentation systems
  • Multi-disciplinary and whole-of-organisation approaches
  • Incorporation of ACP into routine health services
  • Policy alignment with legislation and sector-wide expectations

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C – Comparison

• No formal comparator groupThis was a qualitative synthesis across studies with varied methodology and no consistent control group.However, implicit comparisons were made between organisations/settings with vs. without ACP processes, or before vs. after interventions.

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O – Outcomes

Person-Centred Outcomes:

• Empowerment of residents and families to articulate care preferences
• Concerns from residents about future preferences not being followed
• Emotional burden on families when not supported in ACP processes
• Increased satisfaction when ACP included a person-centred approach 

Process Outcomes:

Six key thematic domains influencing ACP implementation were identified:

1. Knowledge and Education – Low awareness and understanding of ACP among staff, residents, and families limited initiation. Education was a key facilitator.
2. Skills and Training – Staff communication, critical thinking, and leadership skills were essential for successful ACP discussions. Training improved confidence and uptake.
3. Procedures and Resources – Facilitators included clear policies, standardised forms, accessible documentation systems, and time allocation for ACP. Barriers included lack of electronic records and fragmented documentation processes.
4. Perception and Culture – Cultural taboos around death, denial, paternalism, and differing family expectations were significant barriers. Positive perception of autonomy and values alignment facilitated ACP.
5. Legislation – Variability and confusion about state legislation and substitute decision-maker (SDM) roles created uncertainty. Clarification and alignment across jurisdictions were proposed as solutions.
6. Systems – A whole-of-organisation, multi-disciplinary, and standardised approach was seen as ideal. Nurses played a central role in facilitation, supported by GPs and other professionals .

Health System Outcomes:

• Intervention studies reported improved documentation rates post-training (e.g., ACP compliance increased from 50% to 75%)
• No quantitative data on hospitalisation, cost, or resource use were extracted in this review
• System-wide implementation barriers included time constraints and poor inter-sectoral coordination

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Summary Conclusion

This Australian systematic review identified six key domains affecting the implementation of ACP in aged care: knowledge, skills, procedures, perception, legislation, and systems. It found that while education and multi-disciplinary support help, barriers like time pressure, cultural attitudes, and inconsistent legislation hinder sustained uptake. The review strongly recommends a whole-of-system, person-centred approach to ACP, emphasising the role of policy and cross-sector collaboration. It also notes a significant gap in research within community aged care and for CALD, LGBTIQ+, and Aboriginal and Torres Strait Islander populations .

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