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Advance directives in European long-term care facilities: a cross-sectional survey
  1. Paula Andreasen1,
  2. Ulla Harriet Finne-Soveri1,
  3. Luc Deliens2,
  4. Lieve Van den Block2,
  5. Sheila Payne3,
  6. Giovanni Gambassi4,
  7. Bregje D Onwuteaka-Philipsen5,
  8. Tinne Smets2,
  9. Eero Lilja6,
  10. Violetta Kijowska7 and
  11. Katarzyna Szczerbińska8
  12. on behalf of PACE consortium
  1. 1 The Department of Welfare, The Ageing, Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
  2. 2 End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
  3. 3 International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, Lancashire, UK
  4. 4 Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Universita Cattolica del Sacro Cuore, Roma, Italy
  5. 5 Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Center of Palliative Care, VU University Medical Center, Amsterdam, The Netherlands
  6. 6 The Department of Welfare, The Equality and Inclusion Unit, National Institute for Health and Welfare, Helsinki, Finland
  7. 7 Department of Sociology of Medicine, Medical Faculty, Jagiellonian University Medical College, Krakow, Poland
  8. 8 Laboratory for Research on Aging Society, Department of Sociology of Medicine, Medical Faculty, Jagiellonian University Medical College, Kraków, Poland
  1. Correspondence to Paula Andreasen, The Ageing, Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki 00271, Finland; paula.andreasen{at}


Background End-of-life care practices in long-term care facilities (LTCFs) are the focus of growing attention in Europe, due to rapidly increasing number of older persons living in LTCFs. The knowledge about end-of-life discussions or existence of written advance directives in the European LTCFs is scarce. This study’s aim is to investigate the prevalence of written advance directives and their sociodemographic associates, among recently deceased LTCF residents, in six European countries.

Methods Data from the European Union-funded PACE database were collected from 322 LTCFs in six European countries in 2014. The assessments were performed by using two questionnaires designed for LTCF administrative staff and for staff member.

LTCFs were selected within each country by using proportional stratified random sampling procedure. Facilities with certain types and sizes were included from each country.

Multilevel multivariate analyses were performed to evaluate associations between written advance directives and selected predictors.

Results In total, 32.5 % of the 1384 deceased LTCF residents had a written advance directive with a range from 0% to 77 % between countries. The proportion of the most common advance directive, ‘Do not resuscitate in case of cardiac or respiratory arrest (DNR)’, varied correspondingly from 0% to 75%.

LTCF type (OR 2.86 95% CI 1.59 to 5.23) and capability of expressing at the time of admission (OR 3.26 95% CI 2.26 to 4.71) were the independent predictors for advance directive. Residents living in LTCFs where physician was available were less likely to have advance directive compared with residents from LTCFs where physician was not available.

Conclusion Extensive differences for prevalence of written advance directive exist between countries among older LTCF residents in Europe. Timely and appropriate response to LTCF resident’s health needs and preferences efforts advance care planning.

  • advance directives
  • living wills
  • long-term care
  • palliative care
  • hospice and palliative care nursing

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  • Collaborators PACE Consortium.

  • Contributors PA made a research plan that was approved by PACE project’s executive committee. Research proposal was critically reviewed by the authors. Data used in this study’s analysis originate from PACE project Study 1 data collection. LD and LVdB were leaders of PACE project Study 1. All authors substantially contributed to the study’s data collection. GG, HF-S, KS and SP were country leads and they conducted PACE Study 1 survey and data collection in PACE Study 1 partner countries. VK and KS coordinated data collection in Poland. BO-P, EL and TS prepared collected data suitable for this study’s statistical analysis. EL, PA and HF-S performed the statistical analyses in collaboration with TS and LVdB and interpreted and discussed the results with all the authors. All the authors took part in interpreting the results. PA made literature search and wrote all sections of the manuscript. HF-S supervised PA throughout the process. All authors have revised and provided comments to the drafted writing. All authors approved the final version of the manuscript which PA submitted.

  • Funding PACE project is funded by European Union’s Seventh Framework Programme with grant agreement no 603111. The project was cofunded by Polish Ministry of Science and Higher Education in the years 2014–2019 based on the decision no 3202/7PR/2014/2 dated on November 25, 2014. The funders have no involvement in payment of article processing fee.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data relevant to the study are included in the article or uploaded as supplementary information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.