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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. 1Head Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
  2. 2Psychologist, Clinical Ethics, University Hospital Zürich, Zürich, Switzerland
  3. 3Emergency specialist nurse, Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
  4. 4Social Worker and Intensive Care Nurse, Clinical Ethics, University Hospital Zürich/Institute of Biomedical Ethics and History of Medicine University of Zürich, Zürich, Switzerland
  5. 5Statistician, Institute of Primary Care, University of Zürich, Zürich, Switzerland
  6. 6Director of the Institute of Biomedical Ethics and History of Medicine, University of Zürich, Zürich, Switzerland
  7. 7Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
  8. 8Palliative 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

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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.

  • Ethics approval The study was approved by the research ethics committee of the Canton of Zurich, with the study number KEK-ZH 2012–0093 and was registered with the trial number NCT01914848.

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

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