BACKGROUND
-
To determine the effect of advance care planning on the quality of life of patients suffering from heart failure, their satisfaction with end-of-life care through random effects meta-analyses
-
To conduct sensitivity analyses and investigate causes of clinical heterogeneity
-
To explore characteristics of advance care planning interventions that are associated with high and low effect sizes
METHODS
Study Selection
Data Sources and Searches
Data Extraction and Quality Assessment
Data Synthesis and Analysis
RESULTS
Study (years) | Country | Setting | Speciality | Description of healthcare professionals | Description of patients | Patients randomized/completed | Female patients (no/%) / mean age (years) | Follow-up (weeks) | Type(s) of outcome(s) |
---|---|---|---|---|---|---|---|---|---|
Aiken49 (2006) | USA | Community | Palliative Care | Hospice nurse and case manager | HF-NYHA III, IV and COPD | 192/191 | 123/64 68.5 | 12 | QOL |
Au42 (2012) | USA | Hospital | Medicine | Internal and pulmonary physicians | HF-NYHA III, IV, COPD, CRF | 376/306 | 149/53.26 69.4 | 2 | QEOLC |
Brannstrom50 (2014) | Sweden | Hospital | Geriatrics | Geriatricians | CHF, NYHA III–IV | 72/61 | 21/29.1 81.9 | 12 | QOL |
Briggs51 (2004) | USA | Hospital | Medicine | Cardiologists, renal physicians | HF-NYHA II, III, IV and CRF | 27/27 | 11/40.74 68.7 | 1 | QEOLC |
Brumley52 (2007) | USA | Community | Primary and Palliative Care | Primary care and palliative care clinicians | HF-NYHA III–IV, COPD, cancer | 310/297 | 146/49 65.1 | 12 | PSEOLC |
Denvir53 (2016) | UK | Hospital | Cardiology | Cardiology staff | Patients with HF-NYHA III, IV and ACS | 50/44 | 20/40 81.05 | 12 | QOL |
Detering54 (2010) | Australia | Hospital | Medicine Cardiology | Internal and pulmonary physicians, cardiologists | Elderly HF patients >80 years of age | 309/305 | 162/52.5 84.5 | 12 | PSEOLC |
Doorenbos55 (2016) | USA | Hospital | Cardiology | Cardiology staff | HF-NYHA I, II, III, IV | 80/73 | 19/23.7 58.1 | 2 | QEOLC |
Engelhardt56 (2006) | USA | Hospital and community | Primary care and medicine | Primary and secondary care physicians | HF-NYHA III, IV, COPD, cancer | 275/186 | 118/82.6 Not reported | 12 | PSEOLC |
Gade57 (2008) | USA | Hospital | Medicine | Internal physicians | HF, cancer, COPD, stroke, CRF | 517/512 | 162/59 73.3 | 24 | PSEOLC |
Hopp58 (2016) | USA | Hospital | Palliative care | Palliative care clinician and nurse practitioner | CHF patients | 85/85 | 41/48.2 68.1 | 12 | QOL |
Rogers59 (2017) | USA | Hospital | Palliative care cardiology | Palliative care clinicians, cardiologists | Patients with HF-NYHA III, IV | 150/ 106 | 71/47.3 71.9 | 12 | QOL |
Sidebottom60 (2015) | USA | Hospital | Cardiology | Cardiology staff | HF patients | 232/ 167 | 110/47.4 73.4 | 12 | QOL |
Wong61 (2016) | Hong Kong | Hospital | Palliative care | Palliative care physicians and nurses | Patients with HF-NYHA III, IV | 84/ 84 | 41/48.8 78.3 | 12 | QOL |
Characteristics of Included Studies
Effects of ACP on Outcomes for Heart Failure
Meta-analysis on ACP and Quality of Life
Meta-analysis on ACP and Patient Satisfaction
Meta-analysis on ACP and Quality of End-of-Life Communication
Characteristics of ACP Interventions with High and Low Effect Sizes
Study | Outcome | Effect size SMD [95% CI] | ACP characteristics | ACP timing | Education of patient | Involvement of family | ACP follow-up |
---|---|---|---|---|---|---|---|
Sidebottom (2014) | QOL | 0.94 [0.62 to 1.26] | A trained facilitator supports patients to identify their care preferences, completes an ACP health directive and a HF disease-specific care plan | At hospital admission | Yes | Yes | Yes |
Wong (2016) | QOL | 0.74 [0.30 to 1.18] | A complex ACP and transitional palliative care programme with interdisciplinary communication | Before hospital discharge | Yes | Yes | Yes |
Hopp (2016) | QOL | 0.00 [− 0.43 to 0.43] | Single component ACP intervention: one meeting to complete an ACP document, no further patient support | During hospital stay | No | No | No |
Denvir (2016) | QOL | − 0.07 [− 0.67 to 0.52] | An ACP document is discussed with patients, using a multidisciplinary approach and patient electronic records | Before hospital discharge | Unclear | Unclear | Yes |
Detering (2010) | PSEOLC | 0.76 [0.52 to 1.01] | A complex respecting patient choices programme including ACP, identification of patient’s care preferences and surrogate decision maker | Before hospital discharge | Yes | Yes | Yes |
Engelhardt (2006) | PSEOLC | 0.37 [0.03 to 0.70] | A complex ACP coordinated care programme: training patients to ask questions, multidisciplinary approach, increasing patient self-management | Patients were stable | Yes | Yes | Yes |
Brumley (2007) | PSEOLC | 0.22 [− 0.00 to 0.45] | An interdisciplinary, home-based ACP programme including patients’ self-management | Patients were unwell | Unclear | Yes | Yes |
Doorenboos (2016) | QEOLC | 0.48 [0.03 to 0.92] | Pre-outpatient telephone call to train patients in ACP communication and identifying end-of-life care wishes; clinician informed of patient’s wishes before visit | Hospital outpatient visit | Yes | Yes | Yes |
Briggs (2004) | QEOLC | 0.76 [− 0.02 to 1.55] | A single ACP intervention: facilitator has a single 2-h ACP meeting with patient, no interdisciplinary working and no F/u | Before elective admission to hospital | Yes | Yes | No |
Sensitivity Analyses and Heterogeneity
Outcome and subgroups | Studies | Participants | Effect size SMD, 95% CI | I2 |
---|---|---|---|---|
Quality of life (QOL) | 7 | 724 | 0.38 [0.09 to 0.66] | 71% |
Patient population | ||||
QOL HF patients | 6 | 532 | 0.39 [0.04 to 0.74] | 74% |
QOL HF patients + other terminal illnesses | 1 | 192 | 0.28 [0.00 to 0.57] | n/a |
Study setting | ||||
QOL hospital | 3 | 237 | 0.18 [− 0.07 to 0.44] | 0% |
QOL community | 1 | 192 | 0.28 [0.00 to 0.57] | n/a |
QOL hospital and community | 3 | 295 | 0.58 [0.05 to 1.12] | 77% |
Length of follow-up | ||||
QOL F/u to 12 weeks | 7 | 724 | 0.38 [0.09 to 0.66] | 71% |
Patient satisfaction with end-of-life care (PSEOLC) | 4 | 1290 | 0.39 [0.14 to 0.64] | 75% |
Patient population | ||||
PSEOLC HF patients + other terminal illnesses | 4 | 1205 | 0.39 [0.14 to 0.64] | 78% |
Study setting | ||||
PSEOLC hospital | 2 | 765 | 0.49 [− 0.03 to 1.01] | 92% |
PSEOLC community | 1 | 297 | 0.22 [0.00 to 0.45] | n/a |
PSEOLC hospital and community11 | 1 | 143 | 0.37 [0.03 to 0.70] | n/a |
Length of follow-up | ||||
PSEOLC F/u to 12 weeks | 3 | 712 | 0.45 [0.11 to 0.80] | 80% |
PSEOLC F/u to 24 weeks | 1 | 493 | 0.23 [0.05 to 0.41] | n/a |
Quality of end-of-life communication (QEOLC) | 4 | 995 | 0.29 [0.17 to 0.42] | 0% |
Patient population | ||||
QEOLC HF patients | 1 | 80 | 0.48 [0.03 to 0.92] | n/a |
QEOLC HF patients + other terminal illnesses | 3 | 915 | 0.28 [0.15 to 0.41] | 0% |
Study setting | ||||
QEOLC hospital | 4 | 995 | 0.29 [0.17 to 0.42] | 0% |
Length of follow-up | ||||
QEOLC F/u to 4 weeks | 3 | 483 | 0.33 [0.09 to 0.57] | 20% |
QEOLC F/u to 24 weeks | 1 | 512 | 0.29 [0.12 to 0.47] | n/a |
DISCUSSION
Principal Findings
-
Quality of life (SMD, 0.38; 95% CI [0.09 to 0.66])
-
Patient satisfaction with end-of-life care (SMD, 0.39; 95% CI [0.14 to 0.64])
-
Quality of end-of-life communication (SMD, 0.29; 95% CI [0.17 to 0.42]) in heart failure compared to usual care
Comparison with Other Reviews
Strengths and Limitations
Causes of Clinical Heterogeneity
Characteristics of ACP interventions
Potential Reasons for Over- and Underestimation of Effect
CONCLUSIONS AND CLINICAL IMPLICATIONS
-
Introduce ACP at a significant milestone in the patient’s disease trajectory, for example, after an unscheduled hospital admission, before hospital discharge or after a deterioration in the patient’s health status
-
Offer follow-up appointments, preferably two or three meetings or points of contact over a period of time to allow for the clarification and adjustment of care choices
-
Be mindful of ACP preferences
-
Offer the involvement of family members or of a health care proxy
-
Work in a multidisciplinary team and not in isolation within a single medical specialty