Background Patient-centred care is a challenge with very old multiple-disease nursing home residents in case of a medical emergency or end-of-life-situation: as treatment wishes are often unknown and as verbal communication is often limited, the patient`s personal choice of treatment cannot be discerned.

Aim Setting up individual advance care plans to identify, document and communicate treatment wishes in critical situations at the interfaces of medical care.

Methods The project was formed in cooperation between local nursing homes, GP´s, emergency physicians (from 2009 to 2011). For each patient, an individual emergency plan was set up, after discussing with residents, family members, GP`s and nurses.

Results

1. At the project cut-off date (September, 2011), 78 of 534 residents (15%) in 8 nursing homes had received a personal advance care plan. In 96% of these patients their wishes were found to have been respected in regard to places of dying. Caregivers assessed the project positively as having improved the implementation of the residents own will in emergency situations. All nursing homes incorporated emergency planning into their standard care.

2. By the second cut-off date (January, 2015), 163 of 505 residents (32%) had received an advance care plan. The wishes of the residents in regard to places of dying were respected similar (88%).

Discussion and conclusions The implementation of advance care plans highly improves the honouring of residents treatment preferences in emergency situations. The standardised offer of emergency plans is being increasingly accepted. However, the overall implementation continues to be an ongoing challenge.