Systematic Review of Advance Care Planning Implementation in Nursing Homes

Advance care planning (ACP) implementation in NHs is inconsistent and often hindered by systemic challenges. Prior reviews have largely focused on ACP outcomes or discrete implementation factors, with limited attention to the overall implementation process.

To identify elements that can shape ACP implementation quality in NHs using Donabedian's model of quality of care.

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, which was registered at PROSPERO (CRD42024561386). Search terms covering ACP, implementation processes, and assessment were applied across four databases (CINAHL, PsycInfo, SocINDEX, and Medline [Ovid]) in June 2024. Nineteen studies met inclusion criteria, confirmed through independent review and consensus by two researchers.

A deductive thematic analysis, guided by Donabedian's model, identified 11 subthemes under two major themes: (1) NH structural support in ACP, including regulations incorporating ACP into admission, role clarity, and resource availability (e.g., dedicated time and training for ACP, particularly among people with impaired decision-making capacity), and (2) standardized implementation processes, emphasizing resident and family engagement, trust building, discussions of care options and residents' preferences, documentation of ACP in a standardized place, sharing ACP-related information among an interdisciplinary team, and reviewing ACP regularly.

The findings highlighted the need for enhancing NH buy-in for ACP and standardized implementation processes, providing a framework for future NH ACP quality improvement initiatives.