A scoping review of nurse-led advance care planning

Highlights

• Nurses are in key positions to elicit Advance care planning (ACP) discussions.

• This scoping review identified heterogeneous nurse-led ACP models.

• ACP education and training are essential nursing competencies.

• Leaders, researchers, and educators must collaborate to facilitate evidence-based ACP.

Abstract

Background

Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care.

Purpose

This project reviewed and synthesized literature on nurse-led ACP training models.

Methods

A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes.

Findings

Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model.

Discussion

Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.

Introduction

The Institute of Medicine report Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life recommends that clinicians encourage advance care planning (ACP) conversations throughout an individual's lifespan, including childhood if they have capacity to do so (Institute of Medicine, 2014). ACP is a conversation to consider medical decisions that could arise due to serious illness or medical emergencies and convey preferences to loved ones and their healthcare team (National Institute on Aging, National Institute of Health. 2018, Aasmul, Husebo, Sampson, & Flo, 2018). Legal documents, advance directives (AD), are the written portion of ACP that appoints a trusted surrogate decision-maker (medical power of attorney) if one becomes incapacitated (National Institute on Aging, National Institute of Health, 2018) (Aging with Dignity 2020) (AACN 2019b). ACP benefits include improved end-of-life care and satisfaction (Detering, Hancock, Reade, & Silvester, 2010), increased hospice and palliative care use (Bischoff, Sudore, Miao, Boscardin, & Smith, 2013), cost savings due to fewer hospitalizations and aggressive interventions (Bond et al., 2018), diminished decisional conflict of surrogate decision-makers (Chiarchiaro, Buddadhumaruk, Arnold, & White, 2015), and enhanced primary care experiences (Aoki et al., 2017).

ACP, including ADs, has proven benefits, but ADs continue to be underutilized with only one-third of all adult U.S. citizens completing ADs, and even for older adults (≥65 years old), completion rates are only 45% (Lendon, Caffrey, & Lau, 2018; Yadav et al., 2017). The need to magnify ACP endeavors, nurses’ ubiquitous involvement with patients dealing with serious illness (Singer, Goebel, Kim, Sydney, & Lorenz, 2016), and the advocacy focus of nursing has caused national nursing organizations to encourage nurses to increase our national ACP efforts; both the American Nurses Association and the Hospice & Palliative Nurses Association (HPNA) endorse that nurses lead in the promotion and facilitation of ACP to advocate for patient- and family-centered care (American Nurses Association Professional Issues (American Nurses Association Professional Issues Panel 2017; Hospice and Palliative Nurses Association, 2017). The American Academy of Nursing recognizes the importance of nurses at the local, state, territorial, and national level to bridge disparities in ACP (ANA Center for Ethics & Human Rights, 2016; Wicks et al., 2018). A report commissioned by the Robert Wood Johnson Foundation as background for the National Academy of Medicine committee on the Future of Nursing 2020–2030 (National Academy of Sciences, Engineering, and Medicine, 2021) has called for nurses to utilize their history, size, and well-earned trust to tackle the unmet healthcare needs of this century (American Association of Colleges of Nursing, 2019a; Pittman, 2019). While the importance of ACP and the role nurses should play is established, there is no recommended nurse-led ACP training model for nurses.

Multiple factors warrant the identification of an evidence-based, nurse-led ACP training model. Currently, the novel coronavirus disease 2019 (COVID-19) pandemic is a worldwide healthcare challenge that has forced both pre-emptive and urgent ACP conversations (Curtis, Kross, & Stapleton, 2020). Demographically, the United States (U.S.) is an aging population that has a corresponding increase in chronic disease management, and for the first time in U.S. history the older population will outnumber the younger by 2030 (U.S. Census Bureau, 2018). This is coupled with marked racial and ethnic diversity evidenced by rising multi-racial, Asian, and Hispanic populations, thus increasing the healthcare disparities of serious illness and end-of-life care (U.S. Census Bureau, 2018). Yet, a frequently cited barrier is that nurses perceive their lack of education, training, and/or mentorship as a barrier to promoting or facilitating ACP with their patients (Blackwood, Walker, Mythen, Taylor, & Vindrola-Padros, 2019; Christensen, Winters, Colclough, Oley, & Luparell, 2019; Ke, Huang, O'Connor, & Lee, 2015), thus, as nursing professionals, we have yet to bridge our patients’ ACP needs with the knowledge, confidence, and experience within our profession.

Given the importance of this topic in the setting of a lack of high-quality research to support an evidence-based, nurse-led ACP training model, a scoping review was undertaken as the most appropriate methodological framework to systematically identify and analyze the current literature (Levac, Colquhoun, & O'Brien, 2010). The aim was to review and summarize the available literature on current nurse-led ACP training models with a particular focus on: (a) type of ACP training model, (b) nurse-led ACP recipients, (c) ACP models in special populations, and (d) ACP outcomes consistent with Sudore et al. 2018 Organizing Framework (process, action, quality of care, healthcare).