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Advance care plans and hospitalized frail older adults: a systematic review
  1. Sarah A Hopkins1,
  2. Allison Bentley2,
  3. Veronica Phillips3 and
  4. Stephen Barclay1
  1. 1Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  2. 2Department of Psychiatry, University of Cambridge, Cambridge, UK
  3. 3Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
  1. Correspondence to Dr Sarah A Hopkins, Department of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, UK; saah2{at}


Introduction Frail older people are known to have low rates of advance care planning (ACP). Many frail patients prefer less aggressive treatment, but these preferences are often not known or respected. Frail patients often have multiple hospital admissions, potentially providing opportunities for ACP.

Objective To systematically review the literature concerning ACP with frail older people in the acute hospital, with particular reference to: (1) Does ACP improve outcomes? (2) What are the views of patients, relatives and healthcare professionals regarding ACP? (3) Does ACP currently occur? (4) What are the facilitators and barriers to ACP?

Design Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO and Embase databases from January 1990 to May 2019 inclusive. Studies in the acute setting of populations with a mean age >75 years, not focused on a disease-specific terminal condition were included.

Results 16 133 articles were retrieved, 14 met inclusion criteria. No studies used an objective measure of frailty. One randomised controlled trial (RCT) found that ACP improves outcomes for older patients. Although 74%–84% of capacitous older inpatients are receptive to ACP, rates of ACP are 0%–5%; the reasons for this discrepancy have been little studied. The nature of ACP in clinical practice is unknown thus the extent to which it reflects the RCT intervention cannot be assessed. The outcomes that are important to patients are poorly understood and family and physician experiences have not been explored.

Conclusions A better understanding of this area could help to improve end-of-life care for frail older people.

PROSPERO registration number CRD42017080246.

  • communication
  • chronic conditions
  • hospital care
  • prognosis

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  • Contributors All authors contributed to study design. SAH, VP and SB designed the search strategy. SAH, AB and screened abstracts, extracted data and assessed evidence quality. SAH and SB analysed and interpreted the data. SAH drafted the manuscript. All authors provided critical feedback and revisions on the manuscript. All authors approved the final version for submission.

  • Funding SH is supported by the Addenbrooke's Charitable Trust and the Evelyn Trust. SB is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East of England at Cambridgeshire and Peterborough NHS Foundation Trust. He is also supported by the NIHR School for Primary Care Research. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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