Review
Efficacy of Advance Care Planning: A Systematic Review and Meta-Analysis

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Abstract

Objective

To systematically review the efficacy of advance care planning (ACP) interventions in different adult patient populations.

Design

Systematic review and meta-analyses.

Data Sources

Medline/PubMed, Cochrane Central Register of Controlled Trials (1966 to September 2013), and reference lists.

Study Selection

Randomized controlled trials that describe original data on the efficacy of ACP interventions in adult populations and were written in English.

Data Extraction and Synthesis

Fifty-five studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed using the PEDro scale by 2 independent reviewers. Meta-analytic techniques were conducted using a random effects model. Analyses were stratified for type of intervention: ‘advance directives’ and ‘communication.’

Main Outcomes and Measures

Primary outcome measures were completion of advance directives and occurrence of end-of-life discussions. Secondary outcomes were concordance between preferences for care and delivered care, knowledge of ACP, end-of-life care preferences, quality of communication, satisfaction with healthcare, decisional conflict, use of healthcare services, and symptoms.

Results

Interventions focusing on advance directives as well as interventions that also included communication about end-of-life care increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. In addition, interventions that also included communication about ACP, improved concordance between preferences for care and delivered care and may improve other outcomes, such as quality of communication.

Conclusions

ACP interventions increase the completion of advance directives, occurrence of discussions about ACP, concordance between preferences for care and delivered care, and are likely to improve other outcomes for patients and their loved ones in different adult populations. Future studies are necessary to reveal the effective elements of ACP and should focus on the best way to implement structured ACP in standard care.

Section snippets

Data Sources and Searches

A computerized literature search was performed in the databases Medline/PubMed and Cochrane Central Register of Controlled Trials from 1966 through September 2013. The following key words were used: ACP; advance directives; end-of-life communication; life-sustaining treatment preferences; end-of-life decision making; and living will. The key words were combined using ‘or.’ In addition, reference lists of selected articles were searched by hand to identify relevant articles that may have been

Results

In total, 26,628 articles were found in the electronic searches. Fifty-six studies were identified (Table 1). These studies included patients with different diseases and were published between 1992 and 2012 (Figure 1). Fifteen studies (26.8%) recruited participants from an inpatient setting; 37 studies (66.1%) from an outpatient setting; and 4 studies (7.1%) from both settings.

Key Findings

This review systematically evaluated the efficacy of ACP interventions in different adult populations. Interventions focusing on advance directives as well as interventions that also included communication about ACP increased the completion of advance directives and the occurrence of end-of-life care discussions between patients and healthcare professionals. Moreover, interventions that also included communication about ACP in addition to advance directives, also improved concordance between

Methodological Considerations

Included trials had several limitations. First, 55.4% of the trials were classified as “low-quality trials.” The most important reason for low PEDro-scores was the lack of blinding of patients, therapists, and assessors. This may have influenced the findings of the included trials. Indeed, if patients and therapists are not blinded there is a greater risk of response bias and intervention bias, respectively.82 Other highly prevalent limitations were a lack of intention to treat and concealed

Conclusions

In line with our hypothesis, we conclude that ACP interventions increase the completion of advance directives, the occurrence of discussions about end-of-life care preferences, and the concordance between patient's preferences and end-of-life care received in different adult populations. Moreover, ACP interventions are likely to improve other outcomes for patients and their loved ones, such as quality of communication. Further, there seems to be no detrimental effect on anxiety, depression, and

Acknowledgments

All authors were involved in the conception and design of the study and the interpretation of data. Three authors were responsible for the analysis and drafting of the article. All authors revised the manuscript critically for important intellectual content, gave final approval of the version to be published, had full access to all data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. One author is guarantor.

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    The authors have no conflicts of interest relating to this article. This project was supported by Grant 3.4.12.022 of Lung Foundation Netherlands, Leusden, The Netherlands. No funding source had any role in the design or conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review, or approval of the manuscript.

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