Burks Collin E, Salaami Omid, Cantrell Sarah E, Sharda Neema K, Yanamadala Mamata
Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.
Division of Geriatrics, Duke University School of Medicine, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.
J Am Med Dir Assoc. 2023 Oct 27. doi: 10.1016/j.jamda.2023.09.018.
Advance care planning (ACP) interventions are implemented to achieve outcomes such as improving end-of-life care and increasing goal-concordant care. ACP has been studied across various settings, but it is important to study the impacts of ACP in nursing homes.
To review and evaluate the outcomes of ACP interventions in nursing homes.
Systematic review of randomized controlled trials.
A search was last performed on March 27, 2023, using MEDLINE, Embase, CINAHL Complete, Cochrane Library, and clinicaltrials.gov. Eligible studies were randomized controlled trials that studied the impact of ACP interventions in nursing homes with residents over the age of 18. The Cochrane Risk of Bias tool 2.0 was used to determine the studies' risk of bias. The ACP Outcomes Framework was utilized to organize the results into 5 domains: Process, Action, Quality of Care, Health Status, and Health Care Utilization. No meta-analysis was possible because of heterogeneity in study interventions and outcomes.
Twenty-three studies met criteria for inclusion in this review. Most studies were at low or medium risk of bias. The study interventions included resident and family education, staff education, structured discussions, communication with primary medical teams, and use of specialists. A slight majority of Action and Process outcomes were positive, whereas Quality of Care outcomes were mixed. A minority of Health Care Utilization and Health Status outcomes were positive. Multi-component interventions and interventions featuring staff education were often successful.
ACP interventions in nursing homes yield beneficial outcomes in some domains. Limitations to this review include the presence of heterogeneity in types of study interventions and outcomes, as well as underpowering of many study outcomes. Further work is needed to improve ACP implementation, identify which interventions are most beneficial, and ensure sustainability of beneficial interventions.
实施预立医疗计划（ACP）干预措施是为了实现诸如改善临终护理和增加目标一致的护理等结果。ACP已在各种环境中进行了研究，但研究其在养老院中的影响很重要。
回顾和评估养老院中ACP干预措施的结果。
随机对照试验的系统评价。
最近一次检索于2023年3月27日进行，使用了MEDLINE、Embase、CINAHL Complete、Cochrane图书馆和clinicaltrials.gov。符合条件的研究是随机对照试验，研究了ACP干预措施对18岁以上居民的养老院的影响。使用Cochrane偏倚风险工具2.0来确定研究的偏倚风险。利用ACP结果框架将结果组织成5个领域：过程、行动、护理质量、健康状况和医疗保健利用。由于研究干预措施和结果的异质性，无法进行荟萃分析。
23项研究符合纳入本综述的标准。大多数研究的偏倚风险为低或中等。研究干预措施包括居民和家庭教育、工作人员教育、结构化讨论、与基层医疗团队沟通以及使用专家。略多于半数的行动和过程结果是积极的，而护理质量结果则好坏参半。少数医疗保健利用和健康状况结果是积极的。多成分干预措施和以工作人员教育为特色的干预措施往往很成功。
养老院中的ACP干预措施在某些领域产生了有益的结果。本综述的局限性包括研究干预措施和结果类型存在异质性，以及许多研究结果的效力不足。需要进一步开展工作，以改进ACP的实施，确定哪些干预措施最有益，并确保有益干预措施的可持续性。
