The effects of advance care planning intervention on nursing home residents: A systematic review and meta-analysis of randomised controlled trials

Background: Advance care planning is a communication and decision-making process during which people express their wishes for future healthcare and treatment decisions. Advance care planning is particularly relevant to frail older adults. Recently, more advance care planning interventions have been implemented in nursing homes using randomised controlled trial approaches; however, no meta-analysis has been performed evaluating and synthesising the effect of advance care planning in nursing homes. Objective: To determine the effect of advance care planning interventions on end-of-life outcomes in nursing home populations. Design: Systematic review and meta-analysis of randomised controlled trials. Data sources: Medline, EMBASE, Cochrane Library, Medical database, British Nursing Index, PsycInfo and CINAHL Plus from inception to March 2021. Review methods: Randomised controlled trials or cluster randomised controlled trials implementing advance care planning interventions in nursing homes, and studies reporting end-of-life outcomes and published in English were included. Studies in which advance care planning was part of a more comprehensive intervention were excluded. The outcomes were evaluated using pooled odds ratios (ORs) or standardised mean differences (SMDs) with random-effects meta-analysis models. A meta-regression was performed to evaluate the heterogeneity of the included studies. The Cochrane Risk of Bias Tool 2.0 was used to assess the methodological quality of the included studies. Results: Nine trials were identified with 2905 participants, with sample sizes ranging from 87 to 1292. The number of nursing homes involved ranged from 1 to 64. The types of advance care planning intervention differed, with most studies adopting formal education or training for nursing home staff, while the remainder adopted train-the-trainer approaches. The quality of the included studies varied, with two out of nine scoring low in overall risk of bias. Our comprehensive meta-analysis indicated with moderate heterogeneity that advance care planning interventions significantly increased the documentation of end-of-life care preferences (OR = 1.95, 95% CI: 1.64, 2.32), but not satisfaction with end-of-life care from families' perspectives (SMD = 0.08, 95% CI: − 0.08, 0.23). The meta-regression did not identify any variables in advance care planning interventions to explain the heterogeneity. Conclusion: Advance care planning intervention yielded beneficial effects in nursing home residents by increasing the number of documented end-of-life care wishes but demonstrated no effect on satisfaction with end-of-life care from family caregivers' perspectives. This review highlights the need for more rigorously designed implementation studies to examine the effects of advance care planning interventions on healthcare outcomes among frail older adults in nursing homes.