Effectiveness of Advance Care Planning for End-of-Life Outcomes in Nursing Home Residents With Dementia: A Systematic Review and Meta-Analysis.
Review
Overview
abstract
OBJECTIVES: To identify the components of advance care planning (ACP) programs implemented in nursing homes, evaluate the range of associated end-of-life (EoL) outcomes for individuals with dementia and their caregivers, and assess their overall effectiveness. DESIGN: Systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies. SETTING AND PARTICIPANTS: Individuals with dementia in nursing homes, their caregivers, and staff members. METHODS: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception to December 31, 2024. Studies were eligible if they evaluated ACP interventions delivered in nursing home settings and reported EoL outcomes for individuals with dementia and/or their caregivers. Risk of bias was assessed using the Cochrane ROB 2.0 tool for RCTs and the ROBINS-I tool for observational studies. Certainty of evidence was evaluated using the GRADE framework. RESULTS: Ten studies, all conducted in the United States, the United Kingdom, Belgium, France, and Finland, were included; no studies were identified from non-Western countries. Most studies had a moderate to high risk of bias. Owing to heterogeneity in outcome definitions and measurements, the results from the 5 RCTs were not meta-analyzed. Three observational studies assessing the place of death were pooled (n = 1136), showing no significant association between ACP and nursing home death (odds ratio [OR], 1.62; 95% CI, 0.72-3.66; I2 = 69%). Two studies (n = 453) found that ACP significantly increased documentation of do-not-resuscitate (DNR) directives (OR, 14.12; 95% CI, 3.95-50.47; I2 = 0%). Certainty of evidence was very low for both nursing home death and DNR documentation. CONCLUSIONS AND IMPLICATIONS: Although ACP programs in nursing homes may increase DNR directives, evidence of other EoL outcomes remains limited and inconsistent. No included studies were conducted in non-Western settings, highlighting the need for culturally sensitive research and standardized outcome reporting in related research.
