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Advance care planning for the severely ill in the hospital: a randomized trial
  1. Tanja Krones1,
  2. Ana Budilivschi2,
  3. Isabelle Karzig3,
  4. Theodore Otto4,
  5. Fabio Valeri5,
  6. Nikola Biller-Andorno6,
  7. Christine Mitchell7 and
  8. Barbara Loupatatzis8
  1. 1 Head Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
  2. 2 Psychologist, Clinical Ethics, University Hospital Zürich, Zürich, Switzerland
  3. 3 Emergency specialist nurse, Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
  4. 4 Social Worker and Intensive Care Nurse, Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
  5. 5 Statistician, Institute of Primary Care, University of Zürich, Zürich, Switzerland
  6. 6 Director of the Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zürich, Switzerland
  7. 7 Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
  8. 8 Palliative Care Physician, Palliative Care Unit, University Hospital Zürich, Zürich, Switzerland
  1. Correspondence to Tanja Krones, Clinical Ethics, University Hospital Zürich/ Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich CH-8006, Switzerland; tanja.krones{at}usz.ch

Abstract

Objectives To investigate the impact of advance care planning (ACP) including decision aids for severely ill medical inpatients.

Methods Single-centre randomised controlled trial at a Swiss university hospital. Patients were randomly assigned (1:1) to receive an extra consultation with the hospital social service or a consultation with in-house facilitators trained according to an internationally established ACP programme. Trial participants with the exception of the observers were fully blinded. 115 competent severely ill adults, their surrogates and their attending physicians were enrolled and followed for 6 months after discharge or 3 months after death. The patient’s wishes regarding resuscitation (primary outcome), last place of care and other end-of-life wishes were recorded. Knowledge and respect of the patient’s wishes by the surrogates and attending physician were monitored.

Results Compared with controls, 6 months after the intervention, fewer patients wished to be resuscitated or were undecided (p=0.01), resuscitation wishes were documented more frequently (89% vs 64%, p=0.02) and surrogates and/or attending physicians had greater knowledge of the patient’s wishes (62% vs 30%, p=0.01). Groups were not different with regard to wishes being fulfilled, with the exception of last place of care being achieved more frequently in the intervention group (29% vs 11 %, p=0.05).

Conclusion ACP including decision aids offered to severely ill medical inpatients leads to greater knowledge, documentation and respect of treatment and end-of-life wishes. Introducing ACP to these patients however may be too late for many patients. Early integration of ACP during the illness trajectory and a broader regional approach may be more appropriate.

  • advance care planning
  • shared decision-making
  • decision aid
  • randomized trial
  • pragmatic trial
  • resuscitation
  • last place-of-care
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjspcare-2017-001489

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    Supplementary materials

    Footnotes

    • Collaborators ACP experts and consultants:

      Jürgen in der Schmitten, Karen Detering, William Silvester, Hildegard Egolf, Selma Eichenberger, Doris Kropf, Margarete Garlichs, Christel Soom, Wiebke Werner, Denise Viswanathan

      Clinical Trial Centre: Natalie Leu-Möckli, Monika Spitaleri, Monika Brunner, Dirk Smolinski

      Department of Dermatology: Sandra Fluri, Karin Schad, Mirjana Maiwald, Tina Plötz, Lars French, Reinhard Dummer

      Department of Hematology: Markus Manz, Bernhard Gerber

      Department of Internal Medicine: Christlieb Haller, Lukas Zimmerli, Markus Schneemann, Markus Weixler, Edouard Battegay

      Department of Nephrology: Diane Poster, Stefan Segerer, Saskia Heeringa, Kerstin Hübel, Nilufa Mohebbi, Rudolf Wüthrich, Rudi Kleeren

      Department of Neurology: Günter Eisele, Inge Gutmann, Michael Weller

      Department of Oncology: Tamara Rordorf, Alexander Siebenhüner, Rolf Stahel, Bernhard Pestalozzi, Alessandra Curioni, Jörg Beyer, Heidi Dazzi

      Department of Radiation Oncology: Sabine Bader, Matthias Guckenberger, Stefan Obrist, Othmar Immoos, Michelle Brown, Claudia Linsenmeier, Nicolaus Andratschke

      Social Service: Sara Lozano, Martina Stettler

    • Contributors TK was responsible for the concept of materials, ACP facilitation training, study procedures and statistical analysis. She wrote the first draft of the article to which all other authors also substantially contributed during writing up the final manuscript and the revised version of the article. AB in collaboration with FV was responsible for the statistical analysis of the raw data; wrote the statistical analysis part of the article; and made substantial contributions to the revised version of the article. IK and TO collaborated in the development of the educational programme and ACP documentation, were part of the study team, informed patients about the study, and obtained patient data. NBA and CM have been involved in the conceptualization of the study, have reviewed an earlier draft for important intellectual content and have approved the final version. BL together with TK developed the foundation of the ACP concept of the educational programme. In collaboration with TK she was responsible for the design of the study materials, especially the decision aids and the ACP documentation. She was primarily responsible for the educational programme, conducted educational sessions, was responsible for keeping contact with the unitsn and as part of the study team, informed patients about the study, and obtained patient data.

    • Funding This study was funded by Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung and grant number (139255).

    • Competing interests TK, IK, TO and BL work on implementation of ACP in Switzerland and have therefore received honorarium for talks and education on ACP or for work as counsellors of patients regarding ACP.

    • Patient consent Not required.

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

    • 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.