Background Advance Care planning (ACP) has promise as an important strategy to reduce potentially avoidable hospitalizations by eliciting goals and preferences to guide treatment decisions.

Aim To assess the status of ACP implementation for currently enrolled patients approximately halfway through the four-year project.

Methods Participants (n = 1516) are long-stay patients at 19 nursing homes. Nurse interventionists (n = 18 RNs), who are certified Respecting Choices Last Steps POLST (Physician Orders for Life-Sustaining Treatment) are embedded full time in the nursing facilities and engage in ACP discussions as a core function.

Results About half (44% or 665/1516) of patients had engaged in ACP either with the RN or someone else. The most common reason for no ACP was that the RN had not gotten to the resident yet (61% or 521/851). ACP discussions with RNs resulted in a change in orders 74% of the time. About a third (30% or 462/1516) of residents had a POLST form and most (77% or 356/462) were prepared by the project RN. A majority of POLST forms contained orders for Do Not Resuscitate (84%) and Comfort Measures/hospitalise for comfort only (54%).

Discussion Findings suggest that systematic ACP in the nursing home setting is feasible and often results in a change of orders to reflect resident/surrogate preferences. However, competing demands create challenges in the early stages of implementation.

Conclusion Systematic ACP is achievable in the nursing home but requires a champion with dedicated time to engage in conversations.