The impact of advance care planning on end of life care in elderly patients: randomised controlled trial
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1345 (Published 24 March 2010) Cite this as: BMJ 2010;340:c1345
- Karen M Detering, respiratory physician and clinical leader1,
- Andrew D Hancock, project officer1,
- Michael C Reade, physician2,
- William Silvester, intensive care physician and director1
- 1Respecting Patient Choices Program, Austin Health, PO Box 555, Heidelberg, Victoria, Australia 3084
- 2Intensive Care Unit, Austin Health
- Correspondence to: K M Detering Karen.detering{at}austin.org.au
- Accepted 4 December 2009
Abstract
Objective To investigate the impact of advance care planning on end of life care in elderly patients.
Design Prospective randomised controlled trial.
Setting Single centre study in a university hospital in Melbourne, Australia.
Participants 309 legally competent medical inpatients aged 80 or more and followed for six months or until death.
Interventions Participants were randomised to receive usual care or usual care plus facilitated advance care planning. Advance care planning aimed to assist patients to reflect on their goals, values, and beliefs; to consider future medical treatment preferences; to appoint a surrogate; and to document their wishes.
Main outcome measures The primary outcome was whether a patient’s end of life wishes were known and respected. Other outcomes included patient and family satisfaction with hospital stay and levels of stress, anxiety, and depression in relatives of patients who died.
Results 154 of the 309 patients were randomised to advance care planning, 125 (81%) received advance care planning, and 108 (84%) expressed wishes or appointed a surrogate, or both. Of the 56 patients who died by six months, end of life wishes were much more likely to be known and followed in the intervention group (25/29, 86%) compared with the control group (8/27, 30%; P<0.001). In the intervention group, family members of patients who died had significantly less stress (intervention 5, control 15; P<0.001), anxiety (intervention 0, control 3; P=0.02), and depression (intervention 0, control 5; P=0.002) than those of the control patients. Patient and family satisfaction was higher in the intervention group.
Conclusions Advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety, and depression in surviving relatives.
Trial registration Australian New Zealand clinical trials registry ACTRN12608000539336.
Footnotes
Contributors: KMD and WS conceived and designed the study, analysed and interpreted the data, and drafted and revised the article. ADH conceived and designed the study and drafted and revised the article. MCR audited the data, did the statistical analysis, and critically revised the article. All authors gave final approval of the version to be published. KMD is the guarantor.
Funding: This study was carried out using staff employed in the Respecting Patient Choices programme, which receives public funding from the Australian Commonwealth and the Victorian state governments. No external funding was utilised.
Competing interests: All authors have completed the unified competing interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1) no financial support for the submitted work from anyone other than their employer; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; and (4) no non-financial interests that may be relevant to the submitted work.
Ethical approval: This study was approved by the Austin hospital institutional research ethics committee. The trial proposal was submitted on 10 April 2007, some additional information was provided on 7 May 2007, and approval was received on 31 July 2007. See the web extra on bmj.com for the original submission.
Data sharing: No additional data available.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.