Reference, Country Design | Sample & Setting | Inclusion & Exclusion | Intervention | Outcome measures and time points | Findings |
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End of life processes | |||||
Ahronheim et al. 2000 [36] USA RCT | Sample: 99 Response rate: Setting: Hospital Diagnostic group: Advanced dementia Mean age: 84.8 (63–100) | Inclusion: FAST ≥6d, stable at least one month. | Type: Palliative care consultation, discussion with primary care team, family meeting and care recommendations Control: primary care team only | Primary: Mortality, site discharge, length of stay, readmissions DNR orders, systemic antibiotics Secondary: Decision to forgo treatments, decision to adopt palliative care plan. Follow-up: Discharge or in-hospital death | No differences in mortality, readmissions, length of stay. Intervention patients discharged more often with palliative care plan; and more decisions to forgo treatments |
Bailey et al. 2014 [19] USA Stepped wedge | Sample: 6066 Response Rate: Setting: 6 VAMSs Diagnostic group: Veterans who died in centres – any illness Mean age: 71.2 (SD=12) | Staff: 1621 physicians, nurses, residents, allied health, pharmacy, mental health, admin and other Patients: all who died in 6 year period; and subset all who died in 12 month pre and 12 month post-intervention. | Type: Site visits, staff education, decision support tool (CCOS), follow-up consultations during 4 month training period Control: Retrospective chart audit | Primary: % with: Opioid order, DNR order, Location death; Nasogentric tube, IV line infusing, Restraints Secondary: Antipsychotic (order, given) Opioid given, Death rattle medication Benzodiazepine (order, given), PC consult, Pastoral visit, Advance directive, Sublingual admin Follow-up: 12 month-post intervention | Improved orders for opioid, antipsychotic medication, benzodiazepines, death rattle medication, and advance directives. Intervention effects were modest but statistically significant. |
Cugliari et al. 1995 [20] USA CCT | Sample: 419 Setting: 2 hospitals Diagnostic group: mixed Mean age: 53 (SD=16.6) | Inclusion criteria: >18 years, planned admission Exclusion criteria: emergency, obstetrics, psychiatric admission, insufficient English | Type: Written information + 18 min videotape of interviews with adults about experience with advance care planning; and instructions on completing ADs. Control: Written information (usual care) on law on advance directives and health care proxy. | Recall of information Attitudes about ADs and decision to complete proxy | No difference between the groups in recall, understanding of proxy form, completion of form, or perceived importance of ADs. No difference in intention to complete form later. |
El-Jawhari et al. 2010 [21] USA RCT | Sample: 150 Setting: Inpatient internal medicine in two hospitals Diagnostic group: Mixed Mean age: 76 (SD=13) | Inclusion criteria: >60 years, ability to provide consent; communicate in English; advanced cancer, heart failure, COPD, other advanced illness or prognosis <12 months. | Type: 3 minute video on CPR and intubation Preferences for CPR and intubation communicated to 1+ physician Control: Asked for CPR and intubation preferences only | Primary: CPR and intubation preferences Secondary: CPR/intubation orders, documented discussions with providers, patient knowledge CPR/intubation Follow-up: Post-video | Intervention patients more likely not to want CPR and intubation; have documented orders for CPR and intubation; documented discussions of preferences; and higher mean knowledge scores |
Grimaldo et al. 2001 [22] USA RCT | Sample: 185 Setting: Pre-operative evaluation clinic Diagnostic group: scheduled for elective surgery Median age: 73.3 | Inclusion criteria: English speaking; ≥65 years old; scheduled for elective surgery or overnight stay | Type: Usual care + 5–10 minute anaesthetist led information session focusing on the importance of patient-proxy communication about EoL care. Asked if had an AD and offered DPOA paperwork. Control: Standard pre-operative screening and counselling. | Primary: Increased dialogue between pt and proxies in clinic Follow-up: Pre- and post-operatively | Intervention group: Greater proportion who had DPOA at post-operative. More changed response no to yes about DPOA discussions. More likely to have discussions about medical care with proxy |
Jacobsen et al. 2011 [23] USA CCT | Sample: 899 Setting: Two general medical wards Diagnostic group: general medicine, seriously ill Mean age: 63.5 | Inclusion criteria: stable and unstable seriously ill patients admitted to general medicine ward. | Type: Stable pts: patient, family and provider meet to assess knowledge, preferences and experiences. Unstable pts: provider an family meet to recommend about treatment and prognostication. Control: Usual care not specified | Primary: % pts admitted full code without discussion documented % pts admitted full code with discussion documented % pts ACP discussion and order of WLST documented Follow-up: At discharge (record review) | Intervention ward significant better across all outcomes. |
Meier et al. 1996 [24] USA RCT | Sample: 190 Setting: Geriatric inpatient unit Diagnostic group: Elderly Mean age: | Inclusion criteria: >65 years, met Medicare Prospective Payment guidelines, complex care problems | Type: Counselling about advance directives and provided opportunity to complete health care proxy, charting of advance directives and proxy forms. Control: Usual care | Primary: Documentation: (a) copy of proxy form; (b) patient proxy recorded; (c) advance directive notation Secondary: Self-reported quality of care Follow-up: One month | Intervention more likely to complete new proxy or have previously completed proxy identified. |
Nicolasora 2006 [25] RCT | Sample: 297 Setting: Medical ward of teaching hospital Diagnostic group: Mixed Median age: 65 | Exclusion criteria: cardiac catheterization or admission to ICU; documented dementia or delirium (control); of judged by physician to have impaired cognitive function (intervention) | Type: Script about CPR, mechanical ventilation delivered by physician; asked about CPR status; changes communicated to physician; wishes to prepare ADs and assisted with completing ADs Control: Medical records surveyed for in-hospital outcomes and AD status | Primary: Willingness to listen to script; acceptability of information; frequency of changing or choosing CPR status; rate of completion of ADs Secondary: Follow-up: Post-script | 98% willing to discuss CPR and 82% useful 36% intervention had documented code status at admission (vs 34% control) 92% intervention clarified preferences 13/102 without ADs created one after intervention (vs 1/128 control) |
Reilly et al. 1995 [26] USA ITS | Sample: 1780 Setting: Hospital Diagnostic group: mixed | Inclusion criteria: Not reported Patients and staff | Type: Education phase (Reminders, education and feedback to providers); Intervention phase (Standardised AD documentation form placed in medical charts) Control: Not specified | Primary: Frequency and content of ADs documented in charts; Secondary: Pt attitudes about ADs; Provider attitudes about ADs Follow-up: 10 time points (4 control, 3 education and 3 intervention) | Proportion ADs highest during intervention phase (63% vs 23%E vs 25% C) Frequency of ICU ADs and CPRs greater during intervention phase 87% ADs concordant with pt preferences |
Sampson et al. 2011 [27] UK RCT (pilot) | Sample: 33 Response Rate: Setting: Two acute medical wards Diagnostic group: Advanced primary dementia Mean age: 59 (SD=13) | Inclusion criteria: Unplanned admission for treatable acute illness; presence of surrogate that was able to provide informed consent. (FAST stage 6d or worse) | Type: Component 1: 30 minute pt assessment and formulation of management plan. Component 2: Consultations with carers to discuss pts current situation and to provide education about dementia, ACP and PC (these occurred in hospital and in the community post d/c). Control: | Primary: No. carers with ACP Secondary: Carer measures: Distress (KD-10); health status QoL (EQ-5D); Decision making (DCS); decisional satisfaction (DSI); Anger (SAS); Life satisfaction (LSQ); EoL satisfaction (SWC-EOLCD). Patient measures: Pain, distress Follow-up: Patient- 6 weeks; 6 months. Carer-3 months after death. | Seven ACP’s were made in the I group Attrition precluded statistical comparison of groups |
Teno et al. 1997 [25] USA | Sample: 4804 Response Rate: Setting: Five teaching hospitals. Diagnostic group: acute respiratory failure; multiple organ failure with sepsis or malignancy; coma; COPD; CHF; cirrhosis; metastatic colon cancer; NSCLC Mean age: 62 (SD=16) | Inclusion criteria: Presence of diagnosis and ≥18 years of age. Exclusion criteria: d/c or died <48 hours; admitted scheduled d/c <72 hours; non-English speaking; psychiatric ward; AIDS diagnosis; pregnancy; acute burns, trauma.: | Type: Connors et al. + PSDA mandated pt education and documentation of AD’s Control: Usual care not specified | Primary: Awareness, completion and documentation of AD’s; effectiveness of AD’s on decision-making about resuscitation; Physicians role in using AD’s; Surrogates perspectives of AD’s Secondary: Follow-up: 6 months. | Increase in AD documentation in the Post/I group, otherwise the intervention did not affect the pt familiarity with or the use of AD’s. |
End of life outcomes | |||||
The SUPPORT Principal Investigators 1995 [30] (SUPPORT) USA | Sample: 4804 Setting: Five teaching hospitals. Diagnostic group: acute respiratory failure; multiple organ failure with sepsis or malignancy; coma; COPD; CHF; cirrhosis; metastatic colon cancer; NSCLC | Inclusion criteria: Presence of diagnosis and ≥18 years of age. Exclusion criteria: d/c or died <48 hours; admitted scheduled d/c <72 hours; non-English speaking; psychiatric ward; AIDS diagnosis; pregnancy; acute burns, trauma.: | Type: Nurse led intervention: provision of prognostic information to improve communication and decision making. Pt and family EoL preferences elicited and documented. Control: Usual care not specified | Primary: Timing of DNR orders; Pt/physician concordance CPR preferences; Days in ICU before death; Pain; Hospital resource use Secondary: Follow-up: Audit on Days 1, 3, 7, 14 and 35. | Small improvement in Pt/physician concordance in the group. Small increase in reported pain. |
Costantini et al. 2014 [31] Italy CRCT | Sample: 308 Setting: 16 general medicine wards Diagnostic group: Oncology patients and families Mean age:75.6 (SD=10.8) | Inclusion criteria (wards): 25+ cancer deaths per year, hospital consent, specialist palliative care team. Patients who died from cancer and their family member | Type: Liverpool care pathway; training of ward staff and palliative care unit staff; leaflets for family members on emotional and practical issues; audits and feedback; documentation. Control: Usual care | Primary: Overall mean score on toolkit after bereavement interview Secondary: Decision making, ACP, respect, emotional support, coordination care, self-efficacy, quality of care, control of symptoms, processes of care Follow-up: 2–4 months post-bereavement (family); processes 6 months post-implementation. | No difference in overall rating of care. Improvements in 2/9 secondary outcomes only (respect, and control of breathlessness) No difference in survival or medication prescribed |
Detering et al. 2010 [36] AUS RCT | Sample: 309 Setting: Single teaching hospital Diagnostic group: Cardiac, Respiratory, Falls, General admission | Inclusion criteria: ≥80 years old; admitted under internal medicine, cardiology or respiratory medicine; English. Exclusion criteria: Not competent; <80 years of age; expected to die or be d/c within 24 hours; had previous ACP; no family. | Type: Received ACP from trained facilitator: multi-disciplinary collaborative approach to ACP; involvement of a surrogate; documentation of EoL care preferences including CPR Control: Usual medical care, no ACP advice unless specifically requested. | Primary: % pts EOL wishes known and respected Secondary: Patient satisfaction; Impact of death on relatives Follow-up: Baseline, death or discharge of patient; 3 and 6 months post death or discharge. | More decedents in intervention groups had EoL wishes known and respected compared to control (86% vs 30%) A greater proportion of family in I group were satisfied with the quality of death of the patient compared to the C group (83% vs 48%) |
Gade et al. 2008 [32] RCT | Sample: 517 Setting: Two hospitals Diagnostic group: Mixed Mean age: 73.6 (SD=12.6) | Inclusion criteria: 18+ years, hospitalised with 1+ life-limiting illness, attending physician judgement of prognosis <12 months Excluded: cognitive status impaired, no surrogate or currently enrolled in hospice or PC studies. | Type: Palliative care consultation (IPCS) assessing symptoms, assisting goals of care discussions, discharge planning issues, Control: Not specified | Primary: Symptom control, emotional and spiritual support, satisfaction and health care costs Secondary: Follow-up: 2 weeks discharge, 6 months | No difference in hospital LOS IPCS had longer median hospice stays, fewer ICU admissions Higher % IPCS completed ADs at discharge No difference in symptoms, emotional, spiritual support No difference in survival - more IPCS died during index admission Satisfaction higher for intervention patients Total costs lower by $6766 per patient. |
Hanks et al. 2002 [33] UK RCT | Sample: 261 Setting: Hospital Diagnostic group: Cancer and non-malignant inpatients Mean age: 68.4 (26–93) | Inclusion: All inpatient referrals to palliative care team. Exclusion: unable to give consent or complete baseline, unaware of diagnosis, likely to die or be d/c in 24 hours, or needed to be seen very urgently | Type: Full-PCT – assessment by specialist doctor/nurse, provision of advice to team verbally and documented, telephone and in-person follow-up. At least weekly reviews, and liaison with community teams post-discharge. Control: Telephone consultation with senior member of PCT and referring doctor and senior nurse and ward nursing staff | Primary: Symptom control, HrQoL, LOS hospital and rate of re-admission Secondary: Satisfaction patient/family & provider, use of health services. Follow-up: 1 week post-recruitment | Improvement over time in scores for all items in FPCT; and smaller improvements in control No difference between the groups. FPCT discharged home spent fewer days at home, but received more GP visits |
Sidebottom et al. 2015 [34] USA RCT | Sample: 232 Response Rate: Setting: Tertiary hospital Diagnostic group: Heart failure Mean age: 73.4 (SD=13.0) | Inclusion criteria: Acute hearty failure, 18+ years. Exclusion: ICU, undergoing evaluation for transplant or LVAD, post-LVAd or transplant, actively dying, cognitive impairments, insufficient English, existing PC order. | Type: PC consult within 24 hour. Differed to usual consult (1) baseline assessment results available to providers; (2) subsequent consults billed to patients. Referral to ACP process at discharge, post-discharge telephone call if ACP not completed. Control: Usual care | Primary: Symptom burden, depressive symptoms, quality of life Secondary: ACP, inpatient 30 day readmission, hospice use, death Follow-up: 1 and 3 months | Intervention: greater reduction in ESAS distress; improvements in SOB, anxiety and tiredness (1 and 3 mths); pain (3 mths only); lower depression score; higher QoL score. Intervention 2.87 times more likely to complete ACP No difference in readmissions, hospice use, death |
Song et al. 2005 [35] USA RCT | Sample: 32 dyads Response Rate: Setting: Cardiothoracic surgery clinic Diagnostic group: Cardiac condition requiring surgery Mean age: 69.8 (SD= 8.6) | Inclusion criteria: scheduled for semi-elective surgery in 12 or more hours; had decision-making capacity; >50 years of age; had a surrogate >18 years of age willing to participate. | Type: Patient-Centered Advance Care Planning (PC-ACP) interview (20–45 minutes) by trained nurse: i) representational assessment; ii) exploring concerns planning for future medical decision-making; iii) creating conditions for conceptual change; iv) disease-specific statement of treatment preferences; v) summary. Control: Information card on ADs. Offered more information about AD’s if requested. Pts referred to pastoral counselling at their own request. | Primary: Congruence (measured over 3 scenarios) Secondary: Anxiety (SAI); Pt decision making difficulty (16 item decisional conflict scale); Knowledge of ACP. Follow-up: Baseline and post-interview | Intervention group had significantly higher congruence and lower decisional conflict No other differences. |