Implementing a Nurse-led Advance Care Planning (ACP) Intervention in Residential Care Homes

The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.

The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.

The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.

ACP discussion quality will be assessed by the QOC questionnaire, a 13-item instrument that consists of an overall score and two subscale scores for "general communication skills" and "communication about end-of-life care".Residents and family member(s) that have participated in the ACP intervention will be invited to complete the questionnaire at at post-intervention and 2 years after the launch of the ACP intervention.

Informal caregivers' QOL will be assessed by the Quality of Life in Life Threatening Illness--Family Carer Version (QOLLTI-F), a 16-item instrument with seven subscales for state of carer, patient wellbeing, quality of care, outlook, environment, finances, and relationships. Family members participating in the ACP intervention will be invited to completed the questionnaire at baseline (T0), post-intervention (T1), and 2 years after the launch of intervention (T3).

Individual semi-structured interviews will be held at post-intervention (T1) and 1 year after the launch of intervention (T2) with residents and family members (regarding their experience of receiving the intervention) and 2) care homes managers and trained nurses (regarding their experience of delivering the intervention), and allied healthcare workers (including patient care assistants, social workers, and physiotherapists). 20 participants in each group will be invited for interviews. A purposive sampling method will be used with consideration of characteristics of participants and the residential care homes (e.g., high or low rates of ACP completion). Through the interviews, we aim to obtain in-depth understanding of their experience of receiving/implementing the ACP intervention. This approach will enhance the quality of the evaluation of implementation intervention effectiveness and provide insight into further improvements.

The following outcomes will be calculated from the screening and recruitment data: eligibility rate (i.e., the proportion of residents in the intervention group eligible for the study); participation rate (i.e., the proportion of the eligible residents consenting to participant); sample representativeness (i.e., characteristics of residents engaged compared with all eligible residents); organizational adoption (i.e., percentage of RCHs where intervention was intended to be implemented that actually adopted the intervention); and provider adoption (i.e., number and proportion of nurses that attended training and initiated ACP intervention in real practice).

At post-intervention (T1), the intervention group nurses will complete the pre-designed fidelity checklist to assess the intervention fidelity, i.e., the extent to which the intervention components are delivered as planned.