Prevalence, content and significance of advance care planning in nursing home patients

Figures & data

Table 1. Prevalence of diagnoses in the total study population (n = 367).

Diagnosis	Prevalence (n, %)
Cardiovascular disease	274 (75%)
Diabetes	72 (20%)
Dementia	225 (61%)
Pulmonary disease	51 (14%)
Cancer disease	47 (13%)
Stroke	82 (22%)
Psychiatric disease	132 (36%)
Kidney failure	63 (17%)

Table 2. Overview of the content of the advance care plans in the deceased patient’s health records. Advance care planning according to the limited definition (ACP I) was identified in 355 of the total study population of 367.

Variable	Number (%)	Median (range)	Mean (SD)
Number of ACPs per patient		2 (0–7)	2.2 (1.1)
Time from move into NH to first ACP (months)		8 (0–120)	18.5 (23.7)
Time from first ACP at NH to death (months)		8 (0-119)	16.3 (21.0)
Time from last ACP to death (months)		0 (0–37)	1.3 (4.5)
Patient’s preferences^a documented
Patient’s preferences present	117 (33%)
Patient’s preferences missing, no cognitive impairment	34 (10%)
Patient’s preferences missing, cognitive impairment	204 (57%)
Family members involved in ACP
Family members participating^b in ACP	239 (67%)
Family members informed of ACP content	305 (86%)
Do-not-resuscitate order (DNR)	297 (81%)
Hospital care limitation^c	265 (72%)

^aPatient’s preferences concerning direction in care and care limitations. ^bFamily members participating in ACP, physically or by phone. ^cA written instruction in the ACP document to limit hospital care, such as: patient should never receive hospital care, or hospital care only in case of fracture, acute chest pain etc.

Table 3. Adherence to hospital care limitations^a in the care plan (two different definitions: ACP I and ACP II) were evaluated by using frequency of ED visits and inpatient care during the patient’s final six months of life.

Variable	ACP I and hospital care limitations (n = 265)	ACP I and no hospital care limitations (n = 90)	p value	ACP II and hospital care limitations (n = 218)	ACP II and no hospital care limitations (n = 64)	p value
≥ One ED visit(s) during the patient’s final six months of life (n, %)	66 (25%)	50 (55%)	<0.001	53 (24%)	35 (55%)	<0.001
≥ One period of inpatient care during the patient’s final six months of life (n, %)	52 (20%)	48 (53%)	<0.001	40 (18%)	35 (55%)	<0.001

Pearson’s chi-square test was used for group comparisons of categorical data. p values <0.05 were considered significant. ^aWritten instructions in the ACP document to limit hospital care, such as: patient should never receive hospital care, or hospital care only in case of fracture, acute chest pain etc.

Table 4. Overview of associations between advance care planning and background characteristics, physician attendance at nursing home and EOL care.

	No ACP I^an = 12	ACP I n = 355	p value	No ACP II^bn = 85	ACP II n = 282	p value
Background characteristics
Age at death (years; median, mean)	89, 84	89, 88		89, 88	89, 87
Gender (n, %):			0.763			0.280
Female	7 (58%)	227 (64%)		50 (59%)	184 (65%)
Male	5 (42%)	128 (36%)		35 (41%)	98 (35%)
Death in NH	9 (75%)	306 (86%)	0.39	68 (80%)	247 (88%)	0.079
Diagnosis (n, %):
Cardiovascular disease	9 (75%)	265 (75%)	1.00	74 (87%)	200 (71%)	0.003
Diabetes	0 (0%)	72 (20%)	0.13	20 (24%)	52 (18%)	0.300
Dementia	7 (58%)	218 (61%)	1.00	34 (40%)	191 (68%)	<0.001
Pulmonary disease	0 (0%)	51 (14%)	0.39	11 (13%)	40 (14%)	0.771
Cancer disease	3 (25%)	44 (12%)	0.19	11 (13%)	36 (13%)	0.966
Stroke	1 (8%)	81 (23%)	0.31	22 (26%)	60 (21%)	0.372
Psychiatric disease	5 (42%)	127 (36%)	0.76	24 (28%)	108 (38%)	0.090
Kidney failure	2 (17%)	61 (17%)	1.00	23 (27%)	40 (14%)	0.006
Physician attendance
Number of physician consultations at NH during the patient’s final six months of life (median (range), mean (SD))	1 (0–3),	2 (0–10),	0.003	1 (0–10),	2 (0–10),	0.708
	1 (1.0)	2.2 (1.9)		2 (1.9)	2.2 (1.9)
EOL care
Family members informed of the patient’s deterioration	0 (0%)	296 (83%)	<0.001	41 (48%)	252 (89%)	<0.001
Family members informed of the patient’s impending death	0 (0%)	282 (79%)	<0.001	40 (47%)	241 (85%)	<0.001
ED visits during the patient’s final six months of life (median (range), mean (SD))	0 (0–1),	0 (0–4),	0.675	0 (0–2),	0 (0–4),	0.452
	0.3 (0.5)	0.4 (0.7)		0.5 (0.6)	0.4 (0.7)
Inpatient care occasions during the patient’s final six months of life (median (range), mean (SD))	0 (0–1),	0 (0–3),	0.606	0 (0–2),	0 (0–3),	0.317
	0.3 (0.5)	0.4 (0.6)		0.4 (0.6)	0.3 (0.6)
Prescription of palliative drugs for symptom relief	5 (42%)	331 (93%)	<0.001	66 (78%)	270 (96%)	<0.001
‘Benefit for care of closely related person’ certificate^c	0 (0%)	64 (18%)	0.137	10 (12%)	54 (19%)	0.116

Pearson’s chi-square test was used for group comparisons for categorical data. Fischer’s exact test was used when the expected number was less than five in any cell. p values <0.05 were considered significant. Mann Whitney U-test was used for group comparisons of continuous variables because the data was not considered to be normally distributed. Two different definitions of ACP were used: ^aACP I was defined as ‘a proactive plan to handle a future deterioration of the patient, not only to handle a current, specific problem or situation’. ^bACP II included the definition of ACP I, the patient’s preferences concerning medical treatment and care (when cognitive impairment was not a limitation), and the involvement of family members. ^cAn employee’s right to be off work in order to attend a closely related person who is seriously ill and receive financial compensation through Swedish social insurance (In Swedish: Närståendepenning).