Table 4

Summary of main findings of included papers

StudyAimMain findings
Barnato et al 38 Explore uptake of the ACP billing code in the USA5.4% of all admissions involved a billed ACP conversation. The average age among patients with a billed ACP conversation was higher, and the prevalence of cancer, heart failure and dementia was higher in this group. ACP rates varied from 0% to 35% at the hospital-level and 0% to 93% at the physician-level. Most ACP discussions were held by 25% of physicians while a third of physicians never billed for ACP.
Black41 Describe social workers' communication about ADs with hospitalised older patientsSocial workers play an active role in AD communication. The majority felt the amount of time they spend is inadequate.
Black34 Compare nurses' and social workers' roles in AD communication with older patientsBoth nurses and social workers felt their role was to primarily help educate patients about ADs, including their benefits, and also to ensure that families understand a patient's wishes. Nurses were particularly focused on explaining outcomes of particular treatment options, such as cardiopulmonary resuscitation, so that patients could make informed decisions.
Black and Emmet35 Describe nurses' communication about ADs with hospitalised older patientsAspects of communication that nurses reported most frequently were disclosure of information and initiation of topic. Nurses with their own AD were more likely to initiate the topic with patients.
Bristowe et al 29 Compare experience of care when supported by an intervention including ACP with standard careRelatives of patients in the intervention group reported that patients were significantly more likely to have spoken to their doctor about their poor prognosis and to know they may die. Relatives were less likely to feel the information they had received was clear and understandable.
Cantillo et al 39 Design, implement and evaluate an ACP programme, focusing on hospitalised older patientsThe programme interventions included ACP facilitators, clinician and public education, standardised electronic documentation. During the programme, ACP increased from 29% to 87%. No data provided about ACP rates prior to commencement of programme.
Cheang et al 30 Assess prevalence of ACP; to explore the feasibility of an ACP screening interviewNo patients had an ACP in their current medical notes. All patients were at least somewhat comfortable discussing ACP and 82% of patients were very comfortable; 79% of patients said they would be comfortable having further discussions about ACP.
Detering et al 28 Assess whether ACP with older inpatients improves outcomesPatients in the intervention group reported higher satisfaction with their hospital admission.
Among patients who died within 6 months of the intervention (n=56), end-of-life wishes were more likely to be known and respected, family members had lower anxiety, depression and stress and family members were more likely to be satisfied with the quality of the death.
Detering et al 40 Assess feasibility and acceptability of ACP in older non-English-speaking patientsIn patients from a non-English-speaking background, the use of formal interpreters was associated with higher rates of advance care directive completion (p<0.005).
Peck et al 33 Determine the barriers and facilitators to ACP engagement in hospitalSome patients felt hospital was an appropriate time to discuss ACP while others felt it was the wrong time. Some patients were motivated to engage in ACP to achieve certain goals while other patients described focusing their energy on living in the moment and found that engaging in ACP stripped them of this possibility. Some patients felt comfortable discussing death, and making plans in the face of uncertainty, while others felt they could not engage in ACP because they did not know what would happen in the future, or felt that death was unlikely.
Pérez et al 36 Determine opinions of hospital doctors and nurses on ADs43% favoured AD discussions with all ‘elderly’ inpatients, however most doctors did not have an accurate understanding of ADs and had never discussed them with patients.
Schiff et al 31 Determine older inpatients’ knowledge about ADs74% expressed interest in writing an AD. Of those interested in writing an AD, 50% wanted to ensure their wishes were known and 44% wanted to relieve burden on family.
Schiff et al 32 Evaluate an ACP document for older inpatientsIn patients administered the ACP tool, 31% completed an ACP; 22% of patients did not open the information; 84% of patients who completed the feedback questionnaire felt the ACP tool addressed an area of healthcare that was important. Reasons for not completing an ACP included feeling the content was not relevant/they did not wish to discuss end of life care, and wishing to consider further.
Scott et al 37 To develop, implement and assess an ACP programme in an Australian hospitalPre-ACP intervention implementation, 0.6% of patients completed an ACP in hospital, post- ACP intervention, 41% of patients completed an ACP in hospital. Of those approached by a clinician to discuss ACP, 77% completed an ACP. Clinicians did not discuss ACP with 47% of eligible patients. Reasons included discharge prior to discussion, and patient/family felt unable to participate.
  • ACP, advance care planning; AD, Advance Directive.