Recent Clinical Research on Advance Care Planning: 7 Key Takeaways

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Reading Time: 4 minutes

Advance care planning (ACP) is defined as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal of advance care planning is to help ensure that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness.”

Research has found numerous benefits to ACP discussions, including improved quality of life, greater likelihood that healthcare wishes are fulfilled, and less distress among family members and caregivers.

Recently published studies and reports on ACP reveal the following seven crucial points for clinicians to keep in mind:

One: Effective ACP encompasses multiple stakeholders

The goal of this scoping review of ACP randomized controlled trials published over the last decade was to identify effective ACP interventions and outcomes. The authors found that ACP interventions consistently improve patient/surrogate satisfaction with communication and medical care and decrease surrogate/clinician distress. They conclude that ACP should be approached holistically to address the multiple stakeholders involved in the process. (Journal of American Geriatrics Society, Vol. 69, No. 1, 2021)

Two: Older adults face unique barriers that reduce ACP documentation rates

This clinical investigation set out to discover why ACP documentation rates are lower among diverse, vulnerable older adults. Based on validated questionnaires and chart reviews from over 1,200 English and Spanish-speaking patients aged 55 and older with two or more chronic conditions, the investigators identified 26 unique barriers to ACP. The authors conclude that due to the higher barriers among these vulnerable populations, barriers need to be addressed during the ACP process. (Journal of American Geriatrics Society, June 2021)

Three: Interprofessional collaboration facilitates ACP

The objective of this clinical review was to identify gaps and opportunities for promoting collaboration among the different disciplines – chaplaincy, medicine, nursing, psychology, and social work – that contribute to the ACP process. A content analysis of guidelines and recommendations for ACP across the professional organizations reveals a need for standardized competency guidelines to promote effective interprofessional collaboration that will facilitate ACP. (American Journal of Hospice and Palliative Medicine, June 2021)

Four: Nurses play a crucial role in facilitating ACP conversations

A cross-sectional survey was done to assess nurses’ perceptions of facilitating ACP conversations in the Emergency Department (ED). While the benefits of nurse-led ACP interventions have been shown in acute care settings, there is little evidence within the ED. The investigators conclude that as in other settings, nurses in the ED are well-positioned to help patients determine their end-of-life care preferences. The participating nurses indicated that they believe ACP conversations are important and that they feel comfortable with facilitating ACP interventions. (Palliative Medicine Reports, Vol. 2, No.1, March 2021)

Findings from a retrospective systemic review of ACP interventions studies for patients across different stages of dementia found that nurses play a crucial role in implementing ACP. The authors concluded that there should be more nurse-led ACP interventions within this vulnerable patient population. (Journal of Nursing Scholarship, January 2021)

Five: Clinician perceptions can contribute to disparities in ACP

The researchers for this national study wanted to better understand the barriers and facilitators to ACP among clinicians in order to determine how to improve equitable patient-centered end-of-life care. The clinician interviews revealed frequent difficulties with discussing ACP with patients from marginalized racial and ethnic groups, non-native English speakers, and those with certain religious beliefs. The authors conclude that the development of clinician-level and institutional-level interventions are necessary to reduce disparities in ACP. (The Journals of Gerontology, March 2021)

Six: ACP discussions with patients who have serious, life-limiting illnesses should occur early in the disease process

A retrospective study of adults with end-stage liver disease and awaiting liver transplantation found that although these patients were ready to discuss their end-of-life wishes, none had legal ACP forms or their end-of-life care preferences documented in the medical record. The investigators conclude there is an opportunity for tools to facilitate ACP discussions between these patients and their clinicians and caregivers. (Digestive Diseases and Sciences, 2021)

In another study, interviews with older patients with advanced chronic kidney disease (CKD), their care partners, and clinicians revealed conflicting views about who is responsible for initiating ACP and the scope of ACP. Despite the high risk for serious complications and death among this patient population, only about half of the patients interviewed had documented ACP, and most of them had completed it outside the healthcare system. (American Society of Nephrology, June 2021)

Seven: Older, socially isolated adults likely need extra support and guidance to ensure comprehensive ACP completion

The researchers of this study wanted to identify the prevalence and correlates of a “partial approach” to ACP, which involves completing formal documents without an actual discussion. As pointed out by the authors, in situations where the formal ACP documents are completed, but no discussion has occurred, designated decision makers are less likely to know how to decipher an incapacitated patient’s medical wishes. An evaluation of data from 4,836 older adults from the National Health and Aging Trends Study (NHATS) revealed that those who are socially isolated are much more likely to do formal ACP without a discussion. (The Journals of Gerontology, Vol. 76, No. 1, 2021)

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