Advance care planning among older patients may increase patient knowledge, reduce unnecessary hospitalization and reduce stress and anxiety for bereaved families

Weathers E, O'Caoimh R, Cornally N, et al. Advance care planning: A systematic review of randomised controlled trials conducted with older adults Maturitas. 2016 Sep.

Review question

• What impact does advance care planning have on symptom management, quality of care and healthcare use in adults aged 65 or older across all healthcare settings?

Background

• Many older adults at the end-of-life stage (40%) require decision-making about treatment in their final days of life. However, about 70% of adults at this stage lack decision-making capacity due to cognitive impairments, frailty and comorbidities.
• Lack of end-of-life healthcare-decision planning can lead to potentially inappropriate admissions to hospital of frail patients and individuals who would opt out of life-sustaining services if capable of doing so.
• Advance care planning is a process of communication that can be used to discuss and plan future healthcare decisions in case the patient loses their decision-making capacity. However there is a need for assessment of available high-quality studies on advance care planning in order to draw firm conclusions regarding its effectiveness.

How the review was done

• A detailed search of three electronic databases for studies published up to 2015 was conducted. Studies that focused on advance care planning interventions within English-speaking adults (aged 65 or older) within any setting were included in the review.
• A total of 220 studies were identified in searches, and nine were included in the review after assessments for eligibility.
• This review was funded by Atlantic Philanthropies, the Health Service Executive of Ireland, the Health Research Board of Ireland and the Irish Hospice Foundation.

What the researchers found

• Some studies included in the review found that use of advance care planning results in increased documentation of end-of-life care preferences, completion of powers of attorney and completion of advanced-care directives.
• Some studies included found that in terms of patient and family outcomes, there was an increase in patient knowledge of advanced-care directives and life-sustaining treatment, increased concordance between patient end-of-life wishes and treatments, reduction in hospitalization, and lowered stress and anxiety among bereaved families.
• Some studies included suggest that advance care planning interventions in nursing homes and long-term care settings can reduce unnecessary, and sometimes traumatic, hospitalizations of frail older adults.

Conclusion

• This review has found that advance care planning interventions have benefits for patients and family. Furthermore, there is some data suggesting that advance care planning in nursing homes and long-term care settings can reduce unnecessary and potentially traumatic events among the elderly. Overall, the review identifies a need for better studies on the economic impact of advance care planning on healthcare services, and to conclusively determine if advance care planning can improve the quality of end-of-life care.