Challenges in implementing an advance care planning programme in long-term care.
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.
['McGlade|Ciara|C|', 'Daly|Edel|E|', 'McCarthy|Joan|J|', 'Cornally|Nicola|N|', 'Weathers|Elizabeth|E|', "O'Caoimh|Rónán|R|", 'Molloy|D William|DW|']
D032722:Advance Care Planning D060825:Cognitive Dysfunction D004493:Education D000073496:Frailty D006801:Humans D008134:Long-Term Care D009726:Nurses D009735:Nursing Homes D018802:Patient-Centered Care D026684:Personal Autonomy D016730:Program Development D011795:Surveys and Questionnaires D000078329:Workforce
advance care planning long-term care end-of-life care planning capacity Advance care directives dementia living wills older adults