Optimizing Medical Decisions and Care for Adult Orphans
Phase: NA
Conditions: Social Isolation, Health Services Accessibility
Sponsor: Chang Gung University

1 
 
Optimizing Medical Decisions and Care for Adult Orphans 
 
 
 
 
 
 
NCT number: NCT ID not yet assigned 
 
 
Document date: 9 March 2026 
 
 

2 
 
Background 
 
As older adults age, their ability to make decisions may gradually decrease and 
supports from close family members becomes important. The American Geriatrics 
Society defines older patients who lack capacity to make medical decisions, have not 
executed an advance directive to guide medical treatment at hand, and lack family, 
friends, or a legally authorized surrogate to assist in the medical decision-making 
process as unbefriended older adults. This population is challenging for clinicians 
who care for and treat these vulnerable members of society. A second group, defined 
as adult orphans, is comprised of those who retain medical decision-making capacity 
but are at high risk of becoming unfriended due to lack of a completed advance health 
care directive and lack of a surrogate decision maker. Proactive efforts are needed to 
identify adult orphans and prevent them from becoming unbefriended. Unfortunately, 
global studies focusing on identifying this population are limited. The aging 
population in Taiwan is also increasing, which draws attention to the urgent need to 
help clinicians identify and care for adult orphans.  
Aims 
 
Specific aims of this study are as follows. 
1. 
Examine the effectiveness of the training program by assessing clinicians’ 
knowledge, self-efficacy, and clinical practice of caring for adult orphans. 
2. 
Write the final report summarizing the findings of this study. 
 
Method 
Research design 
 
Based on an intensive literature review, a training program for clinicians caring 
for older orphans has been developed. The program will then be implemented and 
evaluated in clinical settings. A randomized controlled clinical trial with 1- and 3-
month posttests will be conducted. The program 
outcomes will be determined by clinicians’ knowledge, self-efficacy, and clinical 
practice about caring for adult orphans. 
Setting and participants 
 
One medical center and one regional hospital will be selected from northern 
Taiwan. A list of clinical divisions (excluding obstetrics and pediatrics) will be 
obtained from each participating hospital. Based on hospital size, four to six divisions 
will be randomly selected from each hospital. The selected divisions will then be 
randomly assigned to the experimental or control group in a 1:1 ratio. 
 
Inclusion criteria: 

3 
 
 
Full-time healthcare professionals working in the selected outpatient or 
inpatient divisions. 
 
Includes physicians, nurses, social workers, and psychologists. 
 
Willing and able to provide informed consent for participation. 
 
Exclusion Criteria: 
 
There are no specific exclusion criteria. All healthcare professionals meeting 
the inclusion criteria are eligible. 
 
Sample size will be estimated using G*power software (version 3.1) for repeated 
measures between two groups (between factors), significance level at 0.05, a small-to-
moderate effect size (f=0.25), and power of 80%. A sample of 43 per group will be 
required. We estimate that at least 100 clinicians will be recruited to participate in this 
study. 
Measures 
 
Data will be collected by a self-report questionnaire that includes scales for 
measuring clinicians’ knowledge, self-efficacy, and clinical practice, as well as a 
demographic form. All measures have been developed by the research team.  
 1. Clinicians’ Knowledge about Caring for Adult Orphans 
 
Knowledge regarding the care of adult orphans measured using the Clinicians’ 
Knowledge about Caring for Adult Orphans Scale, a 17-item questionnaire developed 
by the research team. Each correct response is scored as 1 point and incorrect or “do 
not know” responses are scored as 0 points. Total scores range from 0 to 17, with 
higher scores indicating greater knowledge. 
Unit of Measure: Score on knowledge scale (0–17) 
[Time Frame: Baseline, 1 month, and 3 months after the intervention] 
2. Clinicians’ Self-Efficacy about Caring for Adult Orphans 
 
Self-efficacy in caring for adult orphans measured using the Clinicians’ Self-
Efficacy about Caring for Adult Orphans Scale, a 10-item questionnaire rated on a 5-
point Likert scale (1 = strongly disagree to 5 = strongly agree). Total scores range 
from 10 to 50, with higher scores indicating greater self-efficacy. 
Unit of Measure: Score on self-efficacy scale (10–50) 
[Time Frame: Baseline, 1 month, and 3 months after the intervention] 
3. Clinicians’ Clinical Practice about Caring for Adult Orphans 
 
Clinical practice in caring for adult orphans measured using the Clinicians’ 
Clinical Practice about Caring for Adult Orphans Scale, a 10-item questionnaire rated 
on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Total scores 
range from 10 to 50, with higher scores indicating better clinical practice. 
Unit of Measure: Score on clinical practice scale (10–50) 
[Time Frame: Baseline, 1 month, and 3 months after the intervention] 

4 
 
Intervention program 
 
The Caring for Adult Orphans training program has been developed to improve 
clinicians’ knowledge, self-efficacy, and clinical practice in caring for adult orphans. 
The program consists of three components: A film highlighting issues related to adult 
orphans and unbefriended older adults. A second film introducing the Hospice 
Palliative Care Act and the Patient Right to Autonomy Act to enhance participants’ 
understanding of relevant legal and ethical frameworks. Three common clinical 
scenarios involving the care of adult orphans, used for group discussion and 
structured debriefing. 
 
The training program will be implemented by an experienced, well-trained RA. 
The RA will receive at least three training sessions. In the first session, the PI will 
explain the purpose, design, and procedures of the training program. In the second 
session, the RA will be familiarized with the training program by rehearsal practice. 
In the third session, the RA will practice in the field and discuss related questions. 
The quality of the training program will be ensured by frequent (every 2 weeks for the 
first 3 months and every month thereafter) meetings of the whole team to discuss 
related issues. The content validity index of this program will be examined by a panel 
of 10 experts in geriatric care: four physicians with expertise in treating older adults; 
four clinical nurses, one clinical psychologist and one social worker with extensive 
experience caring for older adults. 
Data collection 
 
Each selected hospital will be approached individually. After the hospitals’ IRBs 
approve the study, we will obtain division lists, delete divisions that do not treat older 
adults, and randomly select four to six divisions based on the size of the hospitals. 
One RA will approach physicians, nurses, social workers, and psychologists who 
work in selected divisions and explain the study by attending their team meetings. All 
clinicians who wish to participate will be asked to sign a consent form and complete 
the pretest (baseline) questionnaire (knowledge, self-efficacy, clinical practice, and 
demographic data). Participants will be assigned to the experimental or control group 
based on group assignment. Clinicians in the experimental group will then receive the 
training program. The control group will not receive any training. All clinicians will 
be asked to complete the same questionnaire (except demographic data) at 1-month 
and 3-month (posttests). 
 
To avoid contamination, the training program will be administered only by one 
RA, and participant recruitment and all data will be collected by another RA who will 
be blinded to the clinicians’ group assignment. The questionnaire will be completed 
anonymously, but participants will be asked to leave the final four digits of their 
mobile phone number at the end of the questionnaire to allow data to be matched from 

5 
 
the three collection times. No information will be compiled about participation 
or nonparticipation in the study. Therefore, clinicians will face no job risk related to 
their participation. 
 
The data-collector RA will be trained in two sessions. In the first session, the PI 
will explain the study purpose, design, and instruments as well as demonstrate how to 
conduct an interview. In the second session, the RA will practice actual data 
collection under the PI’s supervision. 
Data analysis 
 
Data will be analyzed using SPSS for Windows, version 27.0. Group 
characteristics will be analyzed by descriptive statistics, and group differences will be 
identified by t-tests and chi-square for continuous and categorical variables, 
respectively. Differences in group outcomes were analyzed using repeated-measures 
analysis of variance (ANOVA)/analysis of covariance (ANCOVA).