Mitchell SL, et al. - Researchers investigated whether an advance care planning (ACP) video vs usual care impacts documented advance directives, level of care preferences, goals-of-care discussions, and burdensome treatments among nursing home residents with advanced dementia. Among residents with advanced dementia, an ACP video did not impact preferences, do-not-hospitalize (DNH) status, or burdensome treatments, but it did increase directives to withhold tube-feeding, which residents in the intervention arm were more likely to choose with when proxies preferred comfort care.

Methods

• The Educational Video to Improve Nursing Home Care in End-stage Dementia (EVINCE) trial was a cluster randomized clinical trial conducted from February 2013 to July 2017, at 64 Boston-area nursing homes (32 facilities per arm).
• An aggregate of 402 residents with advanced dementia and their proxies (intervention arm, n = 212; control arm, n = 190) were surveyed quarterly for 12 months.
• A 12-minute ACP video for proxies with written communication of their preferred level of care (comfort, basic, or intensive) to the primary care team was the main interventions.
• The percentage of residents with DNH directives by 6 months was the primary outcome.
• Preference for comfort care, documented directives to withhold tube-feeding and intravenous hydration, documented goals-of-care discussions, and burdensome treatments (hospital transfers, tube-feeding, or parenteral therapy) per 1,000 resident-days were the secondary outcomes.
• When comfort care was preferred, exploratory analyses analyzed associations between trial arm and documented advance directives.

Results

• Mean age of the 402 study residents was 86.7 years (range, 67-102 years); 350 were white (87.1%) and 323 were female (80.3%), with DNH directives that by 6 months did not differ between arms (63% in both arms; adjusted odds ratio [AOR], 1.08; 95% CI, 0.69-1.69).
• Findings revealed that preferences for comfort care, directives to withhold intravenous hydration and burdensome treatments did not significantly differ between trial arms.
• Results suggested that residents in intervention vs control facilities were more likely to have directives for no tube-feeding at 6 months (70.10% vs 61.90%; AOR, 1.79; 95% CI, 1.13-2.82) and all other time periods, and documented goals-of-care discussions at 3 months (16.10% vs 7.90%; AOR, 2.58; 95% CI, 1.20-5.54).
• Residents in the intervention arm were more likely to have both DNH and no tube-feeding directives (72.20% vs 52.80%; AOR, 2.68; 95% CI, 2.68-5.85) when comfort care was preferred.