Background: A high prevalence of cognitive impairment and frailty complicates the feasibility of advance care planning in the long-term-care population. Research aim: To identify challenges in implementing the ‘Let Me Decide’ advance care planning programme in long-term-care. Research design: This feasibility study had two phases: (1) staff education on advance care planning and (2) structured advance care planning by staff with residents and families. Participants and research context: long-term-care residents in two nursing homes and one community hospital. Ethical considerations: The local research ethics committee granted ethical approval. Findings: Following implementation, over 50% of all residents had completed some form of end-of-life care plan. Of the 70 residents who died in the post-implementation period, 14% had no care plan, 10% (with capacity) completed an advance care directive and lacking such capacity, 76% had an end-of-life care plan completed for them by the medical team, following discussions with the resident (if able) and family. The considerable logistical challenge of releasing staff for training triggered development of an e-learning programme to facilitate training. Discussion: The challenges encountered were largely concerned with preserving resident’s autonomy, avoiding harm and suboptimal or crisis decision-making, and ensuring residents were treated fairly through optimisation of finite resources. Conclusions: Although it may be too late for many long-term-care residents to complete their own advance care directive, the ‘Let Me Decide’ programme includes a feasible and acceptable option for structured end-of-life care planning for residents with variable capacity to complete an advance care directive, involving discussion with the resident (to the extent they were able) and their family. While end-of-life care planning was time-consuming to deliver, nursing staff were willing to overcome this and take ownership of the programme, once the benefits in improved communication and enhanced peace of mind among all parties involved became apparent in practice.

Background Several randomised controlled trials have tested the effects of advance care planning (ACP) interventions on a range of different outcomes. There is a need to synthesise and analyse these findings to identify gaps in knowledge and make recommendations for further research. Aim The aim of this study was to systematically review the effectiveness of ACP interventions implemented with older adults (>65 years old). Methods A systematic review of the literature was conducted using the CINAHL, PubMed and Cochrane databases from the earliest available date through to September 2014. Results Of the 220 abstracts identified, nine met the inclusion criteria. These studies consisted of a sample of 3,646 older adults (age range 72–88 years). The majority of studies were conducted in the USA (n = 6). Types of ACP interventions, and outcomes measured, varied considerably making it difficult to synthesise the findings. Only two studies were conducted in nursing homes. Most studies did not implement a standardised advance care directive, or measure the impact of interventions on quality of end-of-life care, or on quality of the death and dying experience. Only three studies scored 3 on the Oxford Quality Scale and all had some risk of bias according to the Cochrane Effective Practice and Organisation of Care criteria. Conclusion Further research is needed to assess the impact of ACP interventions on quality of care and on quality of the death and dying experience, particularly in nursing home settings. Future studies should also take into account the economic impact (costs vs benefits).

Background: Quality of dying and death receive far less attention than quality of life. Measuring the quality of care at end-of-life (EOL) in long-term care (LTC) is essential, to ensure high standards.Methods: A questionnaire measuring staff perception of their patient's end of life experience (SPELE) was developed. Content validity (CVI) was assessed by a panel of experts, and piloting was conducted with dyads of healthcare assistants (n = 15) and nurses (n = 15).Results: The SPELE captures facets of the quality of the death and dying experience from healthcare staff's perspective. Good group inter-rater reliability was observed among subscales. One exception was the pain and symptom experience scale. Kappa values showed little agreement between nurses and healthcare assistants for certain symptoms, including pain.Conclusion: Further testing of the questionnaire is required. However it is described as a useful mechanism to enable researchers and clinicians to explore quality of care at EOL. (C) 2015 Elsevier Inc. All rights reserved.

BACKGROUND:The 'Let Me Decide' Advance Care Planning (LMD-ACP) programme offers a structured approach to End-of-Life (EoL) care planning in long-term care for residents with and without capacity to complete an advance care directive/plan. The programme was implemented in three homes in the South of Ireland, with a view to improving quality of care at end of life. This paper will present an evaluation of the systematic implementation of the LMD-ACP programme in the homes.METHODS:Focus groups were conducted with 15 Clinical Nurse Managers and two Directors of Nursing where the programme had been implemented. A semi-structured topic guide was used to direct questions that addressed implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Data was analysed using manifest content analysis.RESULTS:Five key categories emerged, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme included enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision making. Establishing capacity among residents and indecision were among the main challenges reported by staff.DISCUSSION:A number of recommendations were proposed by participants and included multi-disciplinary team involvement, and a blended approach to education on the topic. According to participants relationships with residents deepened, there was a more open and honest environment with family, end of life care focused more on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict.CONCLUSION:The introduction of the LMD-ACP programme enhanced the delivery of care in the long-term care sites and led to a more open and positive care environment.

Background The 'Let Me Decide' Advance Care Planning programme (LMD-ACP) offers a structured approach to End- of- Life (EoL) care planning in long-term care for both residents with and without capacity to complete an advance care directive/plan. The programme was implemented into three homes in the South of Ireland. Aim To qualitatively evaluate the systematic implementation of the 'Let Me Decide' advance care directive and palliative care education programme in three long- term care sites Methods Focus groups were conducted with staff from the homes (n = 17). The sample consisted of 15 Clinical Nurse Managers and two Directors of Nursing. A semi-structured topic guide was used to direct the questions and these addressed the implementation process, challenges implementing advance care planning, advantages/disadvantages and recommendations for the future. Results Five key categories were presented, with 16 corresponding subcategories. These subcategories emerged as a result of 37 codes. Key benefits of the programme ranged from enhancing communication, changing the care culture, promoting preference-based care and avoiding crisis decision-making. Establishing capacity among residents and indecision were among the main challenges reported by staff. A number of recommendations were proposed by participants and included a multi-disciplinary team involvement, and a blended approach to education. Conclusion The LMD-ACP has transcended a number of care issues in the homes. Relationships with residents have deepened, a more open and honest environment with family was created, EOL care is now focused on symptom management, comfort and addressing spiritual care needs as opposed to crisis decision making and family conflict.