Review
Preconditions for successful advance care planning in nursing homes: A systematic review

https://doi.org/10.1016/j.ijnurstu.2016.12.003Get rights and content

Abstract

Objectives

There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs.

Data sources

PubMed, PsycINFO, EMBASE and CINAHL.

Review methods

Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify “preconditions”, defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life.

Main findings

Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home.

Conclusion

There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself.

Section snippets

Background

Advance care planning (ACP) is a continual, dynamic process of reflection and dialogue between patients, family and care providers concerning preferences and values for future treatment and care including end-of-life care, and is aimed at enhancing the concordance between preferences and actual care or treatments received (Teno, 2003, Gillick, 2004a, Singer et al., 1998, Kolarik et al., 2002, Sudore and Fried, 2010, Ahluwalia and Gordon, 2012). If a patient wishes, the contents of such

Methods

We conducted a systematic review of published literature.

Results

Initial database searches yielded 807 references from our first search and 376 from the second. Reference list screening identified three papers (Shalowitz et al., 2006, Lorenz et al., 2008, Street and Ottmann, 2006).

Domain 1: sufficient knowledge and skills

1. An appropriately skilled health-care professional is available for advance care planning at the facility (Sharp et al., 2013, Morrison et al., 2005, Lorenz et al., 2008, Street and Ottmann, 2006, Ashton et al., 2015, Jeong et al., 2010, Rhee et al., 2013, Stewart et al., 2011, Silvester et al., 2012, Chan and Pang, 2010, Bernacki and Block, 2014, Brinkman-Stoppelenburg et al., 2014a, Ke et al., 2015a, Lovell and Yates, 2014, Lund et al., 2015). It is importance that a health-care

Domain 2: willingness and ability to participate in advance care planning

5. Residents, family and professionals are willing to participate in advance care planning (Sharp et al., 2013, Houben et al., 2014a, Ashton et al., 2015, Black et al., 2009, Chan and Pang, 2011, Chan and Pang, 2010, Dickinson et al., 2013, Hall et al., 2011, Shanley et al., 2009, Stewart et al., 2011, Stone et al., 2013, van Eechoud et al., 2014, Einterz et al., 2014, Brooke and Kirk, 2014, Séchaud et al., 2014, Waldrop and Meeker, 2012, Dening et al., 2011, Ke et al., 2015a, Lovell and Yates,

Domain 3: good relationships

10. There is a good relationship between staff and family and between staff and residents (Addicott, 2011, Ashton et al., 2015, Stewart et al., 2011, Stone et al., 2013, van Eechoud et al., 2014, Einterz et al., 2014, Chan and Pang, 2010, Waldrop and Meeker, 2012, Ke et al., 2015a). Disputes between staff and family is often an important barrier to successful advance care planning (Stewart et al., 2011). Additionally, direct contact between physicians and families in the nursing home setting is

Domain 4: availability of an administrative system for documenting wishes and monitoring care

12. There is a written record of the expressed wishes and preferences that is readable, accessible and clear (Morrison et al., 2005, Street and Ottmann, 2006, Dickinson et al., 2013, Shanley et al., 2009, Reinhardt et al., 2014, Séchaud et al., 2014, Wickson-Griffiths et al., 2014, Lund et al., 2015, Ke et al., 2015b, Robinson et al., 2012b, Houben et al., 2014b). The outcome of advance care planning conversations is often measured by the increase in the number of standardized records or

Domain 5: supportive contextual factors

14. There are sufficient resources and time available for ACP (Sharp et al., 2013, Street and Ottmann, 2006, Ashton et al., 2015, Dickinson et al., 2013, Jeong et al., 2010, Einterz et al., 2014, Chan and Pang, 2010, in der Schmitten et al., 2014, Bernacki and Block, 2014, Brooke and Kirk, 2014, Waldrop and Meeker, 2012, Lovell and Yates, 2014, Lund et al., 2015, Ke et al., 2015b). Inadequate resources, additional costs, lack of time and specific tasks that conflict with other job demands are

Discussion

Based on 38 publications with heterogeneous study designs and primarily moderate methodological quality, we have identified 17 preconditions in five domains. These domains are: 1) sufficient knowledge and skills, 2) willingness and ability to participate in advance care planning, 3) good relationships, 4) availability of an administrative system for documenting wishes and monitoring care, and 5) supportive contextual factors. We also identified the different levels to which each precondition is

Conclusion

This systematic review provides a considerable contribution to the evidence base of preconditions for optimal implementation of advance care planning in the nursing home context. Findings support efforts to improve advance care planning by giving particular attention to health-care professionals and the facility, stipulating that a whole-system approach must be taken. This paper also highlights that a theoretical framework such as the Theory of Change is useful to identify preconditions for

Declaration of conflicting interests

None.

Funding

This work was supported by the Research Foundation − Flanders (FWO).

Ethical approval

None.

Acknowledgements

Conception and design of the study and interpretation of data: all authors. Assistance in data analysis: LP, LVdB, CG and LD. Drafting of the article: JG. Critical revision of the manuscript: all authors. All authors gave final approval of the version to be published and take responsibility for the integrity of the data and the accuracy of the data analysis. Guarantor of the study: LVdB. We thank Katrien Alewaeters and Wolters Kluwer for their support in translating the search string.

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