Does advance care planning lead to increased completion of advance directives and selection of surrogate decision makers among frail elders?

In this study, an intensive advance care planning intervention dramatically increased the completion of advance directives and the identification of surrogate decision makers. (LOE = 2b)

Overbeek A, Korfage IJ, Jabbarian LJ, et al. Advance care planning in frail older adults: a cluster randomized controlled trial. J Am Geriatr Soc 2018;66(6):1089-1095.  [PMID:29608789]

Randomized controlled trial (nonblinded)

Foundation

Unconcealed

Other

These researchers conducted a cluster randomized trial of facilitated advance care planning education or usual care among modestly frail elders living in residential care homes or receiving home care nearby. The education intervention included trained facilitators and educational materials and tools intended to identify the patients' goals, values, and preferences regarding their health care and to assist in identifying a surrogate decision maker in the event of noncompetence. In addition to assigning an "activation score" (not all that important), the researchers assessed whether the patient had documented their advance care preferences and had selected a surrogate decision maker. The researchers included 16 clusters that contributed 201 patients (between 1 and 53 patients per cluster). The patients in each group were in their mid-80s and, unsurprisingly, most were female. The intervention patients were more likely to receive home-based care (61%) and to have completed high school (65%) than the control patients (49% and 40%, respectively). At the end of 1 year, 93% of the intervention group had completed an advance directive compared with 34% of control patients (number needed to treat [NNT] = 2; 95% CI 2 - 3). Additionally, 94% of the intervention participants had identified a surrogate decision maker compared with 67% of the control patients (NNT= 4; 3 - 6). Unfortunately, the consultation sessions took an average of 2 hours, including travel time, to complete.