AN ADVANCE CARE PLANNING VIDEO DECISION SUPPORT TOOL FOR NURSING HOME RESIDENTS WITH ADVANCED DEMENTIA: A CLUSTER RCT

Abstract

Background: Better advance care planning (ACP) can help promote goal-directed care in advanced dementia. Methods: Educational Video to Improve Nursing home Care in End-stage dementia was a cluster randomized clinical trial conducted 2013–2017 in 64 Boston-area nursing homes (32 facilities/arm). Advanced dementia residents and their proxies (N=402) were assessed quarterly for one year. The intervention included a 12-minute ACP video for proxies and provision of their preferred level of care (comfort, basic, or intensive) to the primary care team. The primary outcome was the proportion of residents with do-not-hospitalize (DNH) directives by 6 months. Secondary outcomes included: comfort care preference, advance directives, documented goals-of-care discussions, and burdensome treatments/1000-residents days. Exploratory analyses examined associations between trial arm and directives when comfort was preferred. Results: The proportion of residents with DNH directives by 6 months did not differ between arms (AOR=1.08, 95% CI=0.69–1.69). Preferences for comfort, directives to withhold intravenous hydration, and burdensome treatments did not differ between arms. Residents in intervention facilities were more likely to have no tube-feeding directives at 6 months (AOR=1.79, 95% CI=1.13–2.82) and all other time periods, and documented goals-of-care discussions at 3 months (AOR=2.58, 95% CI=1.20–5.54). When comfort was preferred, intervention arm residents were more likely to have both DNH and no tube-feeding directives (AOR=2.68, 95% CI=2.68–5.85). Conclusions: An ACP video did not impact preferences, DNH status, or burdensome treatments among advanced dementia residents, but increased no tube-feeding directives. When proxies preferred comfort, directives in the intervention arm were more likely to align with that preference.