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Advance care planning and caregiver outcomes: intervention efficacy – systematic review
  1. Chetna Malhotra1,2,
  2. Vinh Anh Huynh1,
  3. Mahham Shafiq1 and
  4. Ada Portia M Batcagan-Abueg1
  1. 1 Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore
  2. 2 Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
  1. Correspondence to Dr Chetna Malhotra, Lien Centre for Palliative Care, Duke-NUS Medical School, Singapore, Singapore; chetna.malhotra{at}


Context Caregivers make difficult end-of-life (EOL) decisions for patients, often adversely affecting their own psychological health. Understanding whether advance care planning (ACP) interventions benefit caregivers can enable healthcare systems to use these approaches to better support them.

Objective We conducted a systematic review and meta-analysis to identify and quantify the impacts of ACP interventions on caregiver outcomes.

Methods We searched MEDLINE, Embase and Cochrane databases for English-language randomised or cluster randomised controlled trials (RCTs) published until May 2021. Two reviewers independently assessed methodological quality using the Physiotherapy Evidence-Based Database Scale. We conducted a narrative synthesis for each outcome. Difference between arms with a p value of <0.05 was considered statistically significant.

Results Of the 3487 titles reviewed, 35 RCTs met eligibility; 68.6% were rated high quality. Included RCTs were heterogeneous in intervention characteristics, setting and disease. Meta-analysis of 17 RCTs showed that ACP had large and significant improvement in congruence in EOL care preferences between caregivers and patients (standardised mean difference 0.73, 95% CI 0.42 to 1.05). The effect of ACP on this outcome, however, declined over time. We also found some evidence that ACP improved bereavement outcomes (three of four RCTs), satisfaction with care quality/communication (four of the six RCTs), reduced decisional conflict (two of the two RCTs) and burden (one RCT). No study showed that mental health of caregivers were adversely affected.

Conclusion The review provides most comprehensive evidence about the efficacy of ACP on caregiver outcomes. Findings suggest some evidence of benefit of ACP on caregiver outcomes.

  • Communication
  • Bereavement
  • End of life care
  • Family management

Data availability statement

Data are available in a public, open access repository. No data are available.

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Data availability statement

Data are available in a public, open access repository. No data are available.

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  • Contributors CM is the guarantor of the study. MS and APMB-A conducted literature search, abstraction and review of quality. VAH conducted data analysis and meta-analysis of the included studies' results. CM wrote the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.