Garden, Gill
(2021)
Are the benefits of advance care planning for care home residents, as demonstrated by research studies, seen when implemented in a large-scale clinical service offering advance care planning for care home residents as part of Comprehensive Geriatric Assessment (CGA)?
PhD thesis, University of Nottingham.
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Abstract
Introduction
Care home residents have a short life expectancy and are more likely to have emergency admissions than people of the same age living in the community. Although such admissions may resolve crises, maintain and restore functional and relieve physical and mental distress, there is evidence that hospital admission may be burdensome or detrimental to the health of older people with severe frailty. Furthermore, admission may not reflect their wishes, or those of their families. Advance care planning is a means by which care home residents can express their health care preferences, not only regarding admission to hospital, but also their choices in relation to other aspects of their care.
I conducted a systematic review which found that some research studies showed that advance care planning for care home residents was associated with reduced hospital admissions and increased proportions dying in the care home. The evidence appeared stronger for advance care planning educational interventions than interventions delivered by specialist teams, but there was much less evidence as to whether these findings could be replicated in routine practice.
Aims
The research questions this thesis asked was whether Advance Care Plans (ACPs):
• could be implemented in unselected care homes
• were acceptable to care home residents
• were associated with reduced hospital admissions
• were associated with more residents dying in their preferred place of care.
Methods
To test this research question, a service was implemented and evaluated in Lincoln, UK. The intervention involved a multidisciplinary team trained in comprehensive geriatric assessment and the use of ACPs and led by me. The effect of this service on hospital admissions was evaluated using a step wedge randomised control designed study, under clinical governance, using routine hospital and mortality data. The extent to which the intervention was delivered was evaluated using routine service records. A trustworthiness framework was used justify the credibility, dependability, confirmability, transferability and authenticity of the use of field notes, multidisciplinary team meeting and diary records, and reports from residents’ electronic primary care records obtained during the implementation and delivery of the service and the results of the quantitative study to formulate retrospectively a synthesis using soft systems methodology and a widely used framework for understanding service implementation, the Consolidated Framework for Implementation Research.
Results
I found that:
• Advance care planning could be implemented in 68% of care homes
• ACPs were acceptable to almost 80% of residents, similar levels to research trials
• the intervention did not lead to a reduction in hospital admissions, but rather a trend towards increased admissions
• Possession of an ACP was associated with a greater chance of dying in the care home which, for most residents, was their preferred place of care
• Residents were more likely to opt for active medical treatment while their function remained good, whereas residents with greater frailty were more likely to emphasise preference for palliative care
The synthesis illustrated that, in implementation of the project, multiple interfaces needed to be considered, including individual residents, their families, care homes and general practices, local health and social care organisations, and the wider context of a whole system experiencing increasing financial constraint and organisational change.
Discussion
This service successfully delivered ACPs alongside a comprehensive geriatric assessment, although not all care home managers co-operated. Most residents in whom ACPs were put in place opted for their preferred place of death to be the care home, and having an ACP increased the likelihood of doing so. However, hospital admissions were not reduced.
Although advance care planning is not a new concept to palliative care in the UK, most NHS staff, and the Lincolnshire population, were unfamiliar with the concept. Thus, implementation of a relatively novel concept for residents of care homes in Lincoln presented challenges.
Importantly, care home residents were able to have their choices formalised and communicated to stakeholders, including primary care and out of hours services. The failure to demonstrate a reduction in admissions was likely to reflect several factors, including residents’ choice for active intervention, and lack of community services to support implementation of ACPs. However, in a climate of economic austerity, no reduction in admissions has implications for future funding and sustainability of advance care planning. The importance of proactive use of implementation science models for future implementation is proposed.
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