Background The risk of life-threatening illness increases with frailty, and comorbidities, as indicated by rising rates of life-sustaining treatments. These, almost automatically applied, may evoke suffering, risk of traumatization of relatives and strain on treatment teams. for carrying out treatments according to patients‘ preferences, instruments like advance directives have become established in Germany. Data presented here, show the prevalence of advance care plans and the rate of treatment decisions in which nursing home (NH) residents’ preferences were known and honoured in life-threatening events before implementing advance care planning (ACP).

Methods Data were collected in the cluster-randomized controlled trial (BEVOR), which investigated the effects of a regional ACP program in 44 NH in Germany. The rate of advance care plans (advance directives, health care proxy designation, emergency orders) based upon aggregated routine NH data of 4350 residents and was collected by trained NH staff between 04–11/2020. The rate of ‘care consistency with care preferences’ based upon a data collection of 892 residents. It includes: records search, interviews with residents, surrogates and staff. The information is summarized in an integrated judgment by trained study staff.

Results 44% (±13%) of residents had an advance directive, 5% (±8%) an advance directive by proxy, and 3% (±7%) an emergency order. In 5% of life-threatening events, these documents applied. 63% (±22%) had a health care proxy on file. On average, the documents date back to 2014. In 15% of all treatment decisions in the event of a life-threatening decision the residents’ preferences were known and honored.

Conclusion Great potential for improvement in the implementation of respecting patient preferences in life-threatening situations was shown. To achieve this, an improved decision-making culture in the sense of (advance) shared decision making and an increase of meaningful and reliable documents can be strived for, as outlined in ACP programs.