End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Laarbeeklaan 103, 1090 Brussels, Belgium.
Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35, Box 7001, 3000, Leuven, Belgium.
BMC Geriatr. 2018 Feb 14;18(1):47. doi: 10.1186/s12877-018-0723-5.
Advance care planning (ACP) has been identified as particularly relevant for nursing home residents, but it remains unclear how or under what circumstances ACP works and can best be implemented in such settings. We aimed to develop a theory that outlines the hypothetical causal pathway of ACP in nursing homes, i.e. what changes are expected, by means of which processes and under what circumstances.
The Theory of Change approach is a participatory method of programme design and evaluation whose underlying intention is to improve understanding of how and why a programme works. It results in a Theory of Change map that visually represents how, why and under what circumstances ACP is expected to work in nursing home settings in Belgium. Using this approach, we integrated the results of two workshops with stakeholders (n = 27) with the results of a contextual analysis and a systematic literature review.
We identified two long-term outcomes that ACP can achieve: to improve the correspondence between residents’ wishes and the care/treatment they receive and to make sure residents and their family feel involved in planning their future care and are confident their care will be according to their wishes. Besides willingness on the part of nursing home management to implement ACP and act accordingly, other necessary preconditions are identified and put in chronological order. These preconditions serve as precursors to, or requirements for, accomplishing successful ACP. Nine original key intervention components with specific rationales are identified at several levels (resident/family, staff or nursing home) to target the preconditions: selection of a trainer, ensuring engagement by management, training ACP reference persons, in-service education for healthcare staff, information for staff, general practitioners, residents and their family, ACP conversations and documentation, regular reflection sessions, multidisciplinary meetings, and formal monitoring.
The Theory of Change map presented here illustrates a theory of how ACP is expected to work in order to achieve its desired long-term outcomes while highlighting organisational factors that potentially facilitate the implementation and sustainability of ACP. We provide the first comprehensive rationale of how ACP is expected to work in nursing homes, something that has been called for repeatedly.
预先医疗照护计划（ACP）被认为与养老院居民特别相关，但目前尚不清楚 ACP 如何发挥作用，以及在这种环境下如何最好地实施。我们旨在制定一个理论框架，概述 ACP 在养老院实施的假设因果途径，即预期会发生哪些变化、通过哪些过程以及在什么情况下发生。
变革理论方法是一种参与式的方案设计和评估方法，其基本意图是提高对方案如何发挥作用以及为什么发挥作用的理解。它产生了一个变革理论图，直观地展示了 ACP 在比利时养老院环境中预期如何发挥作用、为什么发挥作用以及在什么情况下发挥作用。使用这种方法，我们整合了与利益相关者（n=27）进行的两次研讨会的结果、背景分析和系统文献综述的结果。
我们确定了 ACP 可以实现的两个长期结果：提高居民意愿与他们所接受的护理/治疗之间的一致性，并确保居民及其家属参与未来护理计划，对他们的护理将符合他们的意愿有信心。除了养老院管理层实施 ACP 的意愿和相应行动外，还确定了其他必要的前提条件，并按时间顺序排列。这些前提条件是成功实施 ACP 的前提或要求。在几个层面上（居民/家属、员工或养老院）确定了九个原始关键干预组件，具有特定的理由，以针对前提条件：选择培训师、确保管理层参与、培训 ACP 参考人员、为医护人员提供在职教育、为员工、全科医生、居民及其家属提供信息、ACP 对话和文件记录、定期反思会议、多学科会议以及正式监测。
这里呈现的变革理论图说明了 ACP 如何发挥作用以实现其预期的长期结果的理论，同时强调了组织因素，这些因素可能促进 ACP 的实施和可持续性。我们提供了 ACP 在养老院中预期如何发挥作用的第一个全面理由，这是人们多次呼吁的。
