Implementation and evaluation of Goals of Patient Care medical treatment orders in residential aged care facilities: a mixed methods study

© 2017 Dr. Ruth Simone MartinBackground: Systematic reviews demonstrate that Advance Care Planning has many positive effects for residents of residential aged care facilities, including decreased hospitalisation. The proposed residential aged care facility “Goals of Patient Care” form uses shared decision-making to incorporate a resident’s prior Advance Care Planning into medical treatment orders. Where no written Advance Care Plan exists it captures residents’ known values and preferences. This documentation guides healthcare decision-making at a time of clinical deterioration. Method: A mixed methods study design was used incorporating (i) a cluster randomised controlled trial and (ii) an explanatory descriptive study. The cluster randomised controlled trial took place in three pairs of residential aged care facilities over twelve months in 2015-2016. In Intervention facilities Goals of Patient Care discussions and forms were completed by a Medical Practitioner, following a shared decision making process, incorporating Advance Care Plans or preferences. In Control facilities residents had usual care, which frequently included an Advance Care Plan¬¬. The primary hypothesis was that the Goals of Patient Care process was superior to standard Advance Care Planning alone leading to decreased hospitalisation due to clearer documentation of residents' medical treatment plans. The primary outcome was the effect seen on Emergency Department attendances and emergency admissions at six months. Secondary outcomes included change in hospitalisation rates at three and twelve months, total hospital bed days and In-RACF and In-hospital mortality rates. The explanatory descriptive study took place in the Intervention facilities alone twelve months post Goals of Patient Care implementation. Focus groups and semi-structured interviews were conducted to evaluate both Advance Care Planning and Goals of Patient Care from a healthcare professional’s point of view. Open and axial coding of themes was used to analyse this data. Results: Over 70% of patients participated. The facilities were pooled for analysis with 181 residents were randomised to Intervention and 145 to Control. In the cluster randomised controlled trial the primary outcome of a 40% reduction in Emergency Department attendances and emergency admissions compared with Control facilities at six months was not attained with Incident Rate Ratio of 0.74, 95% CI: 0.49–1.14, p=0.170. There was a near 50% change in Cluster 3, but not in Cluster 1 and 2. In the Intervention group 11/61 (20.4%) Emergency Department attendances did not result in admission while in the Control group a significantly higher, 20/54 (32.7%) did not result in hospital admission. There was no difference seen in mortality in the groups at six or twelve months. In terms of secondary outcomes the Intervention resulted in a 40% reduction in Emergency Department attendances and emergency admissions at twelve months with IRR=0.62, 95% CI 0.39-0.99, p=0.043. There was a trend toward decreased total hospital bed days in Intervention versus Control facilities. Mortality rates at all time-points show increased likelihood of dying in the facility rather than hospital, which was the preference for our participants. This was statistically significant at six months with RRR 2.21, p=0.008 95% CI 1.23-3.98. Qualitative analysis identified four major themes; Completing an Advance Care Plan; Activating an Advance Care Plan; End-of-life; GOPC. Both ACP and GOPC was seen as a valuable addition to improve patient care and help residents engage with their own preferences. Barriers to successful ACP included poor health literacy, mistrust, ambivalence to activate the plan by family and varying involvement from General Practitioners. Conclusions: Goals of Patient Care medical treatment orders were not effective in reducing Emergency Department attendances and emergency admissions at six months post intervention. Secondary outcomes did find that Goals of Patient Care medical treatment orders were more effective than standard Advance Care Planning for decreasing hospital transfers and decreasing likelihood of dying outside the facility. The shared decision making process results in medical treatment plans that take better account of both: the resident’s values and preferences; and the medical interventions suitable for their care. Barriers to successful completion and activation of plans still exist and education of all stakeholders would help address these issues