Abstract

In Singapore, most voluntary nursing homes(VNHs) residents with next-of-kins(NOKs) do not receive advance care planning(ACP). A local hospital embarked on a pilot program, Project CARE (PC), to conduct formal ACP and enable enhanced palliative care delivery in selected VNHs.

This pilot cohort study of six VNHs residents included those with advanced medical conditions(UK Gold Standards Framework criteria) with Modified Shah Barthel Index score <30. Excluded are residents <65 years old (unless satisfied inclusion criteria), without NOKs and decision making capacity(DMC), or on police evaluation. ACP were initiated with documentation of preferences on cardiopulmonary resuscitation (CPR), medical intervention(comfort, limited intervention, full treatment) and place of death. Residents would be enrolled into PC when preferences were for comfort care/limited intervention in nursing home without or with further treatment at hospital. Hospital team would co-manage with VNHs during residents' deterioration. Outcomes are evaluated from program inception on September 2009 till January 2011.

Of a total of 1464 residents, female(55.1%), Chinese(88.8%) and age ≥75 years old(61.7%) predominated. 54.4% of residents fulfilled criteria for possible ACP. Of this latter group, 51.2% completed ACP with 46.3% enrolled into PC. 4 NHs with minimum 6 months of patient reviews in PC framework were further evaluated with 153 deaths recorded. Success in honouring preferences on medical intervention and death place while in PC were 89.4% and 66% respectively. Mortality rate among eligible residents but without ACP yet, had ACP and in PC/not in PC were 24.6%, 25.8% and 24.2% respectively.

Care preferences could be honoured under PC framework.