Preparing Surrogates of Dementia Patients Through an Advance Care Planning Intervention

Study Overview
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Brief Summary
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The goal of this clinical trial is to evaluate the effects of a nurse-facilitated post-discharge advance care planning intervention with family surrogates of dementia patients on outcomes that reflect the preparedness of surrogates in decision-making. The main question it aims to answer is, whether the ACP intervention as compared with usual care will increase family surrogates' self-efficacy in surrogate decision-making and reduce their levels of distress, and increase patient comfort and reduce acute healthcare utilization at 2 and 6 months. Participants will be randomized to ACP intervention vs. usual care. patients of the Intervention group will be assessed on palliative care needs, and surrogates of the Intervention group will participate in 2-3 nurse-led ACP consultations; surrogates of both intervention and control groups will complete 3 surveys at different time points during their participation of the study. Researchers will compare the intervention group and control group to see any differences in: surrogate preparedness for decision-making, distress of surrogate and satisfaction with the care of loved one with dementia at the end-of-life, enrolment in Community Geriatric Assessment Team end-of-life care program, advanced care program documentation in medical record, patient comfort at end-of-life, hospitalizations in the last 6 months of life.

Detailed Description
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In order to test the ACP interventions that aim to engage surrogates' participation in ACP and improve their preparedness for decision-making rather than on documentation of advance care plans alone, the research team has developed a pilot structured, nurse-facilitated post-discharge ACP intervention with the aim to improve surrogates' preparedness for in-the-moment decision-making. It does so by incorporating best practices for ACP communication, drawing from prior work of the research team and existing literature, combined with a focus on developing surrogates' self-efficacy for decision-making guided by Bandura's Social Cognitive Theory. This application aims to test the intervention's effects on surrogate outcomes (decision-making self-efficacy and distress), patient outcomes (patient comfort and healthcare utilization), as well as process outcomes (ACP documentation, end-of-life care discussions between family members, and enrolment in end-of-life care programs). The research hypotheses to be tested are as follows: the investigators will test whether the ACP intervention as compared with usual care will increase family surrogates' self-efficacy in surrogate decision-making and reduce their levels of distress, and increase patient comfort and reduce acute healthcare utilization at 2 and 6 months.

Official Title
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Preparing Surrogates of Dementia Patients for In-the-moment Decision Making Through a Structured Advance Care Planning Intervention: A Mixed-methods Pilot Study

Conditions
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Dementia

Intervention / Treatment
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* Other: Nurse-facilitated advance care planning intervention


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for the Patient-Surrogate dyad: Patient (a) at or above the age of 60 years old, (b) with diagnosis of dementia based on DSM-5 Criteria for Major Neurocognitive Disorder and Stage 6d or above on the Global Deterioration Scale (GDS), (c) residing in a residential care home that is participating in Hospital Authority Enhanced Community Geriatric Assessment Team End-of-Life (CGAT EOL) Care program and (d) has an eligible family decision-maker. Surrogate (a) at or above the age of 18 years old, (b) identified as the patient's next of kin or legal guardian who is the 'key decision maker' in hospital records, and (c) able to provide informed consent for him/herself and the patient. Exclusion Criteria: - Patient with (i) prior completed advance directive, (ii) prior decision regarding feeding tube insertion due to feeding problems was made in conjunction with a healthcare provider, (iii) currently enrolled in an end-of-life care program or palliative care service, or (iv) with family members who lack consensus on the primary family surrogate decision-maker.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: The investigators will use a sequential mixed-methods approach including a pilot randomized controlled trial using a quantitative study to evaluate the effects of a structured nurse-facilitated ACP intervention and a qualitative study to explore the perceptions of the family surrogates and the ACP nurse facilitator on the ACP intervention. Each patient-family dyad will be randomized in a 1:1 ratio to ACP intervention vs. usual care before the baseline interview.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: ACP Intervention arm<br>The group which will participate in nurse-facilitated advance care planning intervention. | Other: Nurse-facilitated advance care planning intervention<br>* The intervention consists of two components: Component 1. Palliative care needs assessment - The research nurse will conduct a palliative care needs assessment and also review related information from the medical chart, which will enable the nurse to provide tailored information on the patient's illness, prognosis, and palliative care needs during subsequent ACP consultations. Component 2: Structured nurse-facilitated ACP consultations - The research nurse will conduct post-discharge ACP consultations with the family surrogate, with content that includes: assess readiness for discussions, introduce video decision aides to provide related ACP information and share examples of family surrogates with similar experiences.<br>|
| No Intervention: Usual care arm<br>The group which will not participate in nurse-facilitated advance care planning intervention. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Modified Family Member Decision-Making Self-efficacy Scale (FDMSE) - Chinese version | This is a modified 17-item version of the FDMSE, a valid and reliable scale that quantifies a family member's confidence (0-100, where 100 = greatest self-efficacy) in end-of-life care decision-making for a loved one. | Baseline, 2-month, 6-month | 
| Family Distress in Advanced Dementia Scale (FDAD) - Chinese version | The FDAD is a validated 21-item scale rated on a 1-5 scale, with higher scores indicating greater family distress. | Baseline, 2-month, 6-month | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| End-of-life care discussions with other family members | The number of conversations which the surrogate has with other family members regarding end-of-life care decisions for the patient with advanced dementia. | Baseline, 2-month, 6-month | 
| Documentation of ACP discussions with medical providers | Information on the date of ACP discussion, type of clinician(s) involved, and care decisions in the Hospital Authority Clinical Management System. | Baseline, 2-month, 6-month | 
| Enrolment in Community Geriatric Assessment Team End-of-Life (CGAT EOL) care program | Occurrence and date of new enrolment in the CGAT EOL care program in the Hospital Authority Clinical Management System. | 2-month, 6-month | 
| Comfort Assessment in Dying with Dementia (CAD-EOLD) | Measure of common symptoms and conditions to assess comfort of advanced dementia patients across 4 domains: Physical Distress, Emotional Distress, Well Being, and Dying Symptoms. | 2-month, 6-month | 
| Unplanned hospital admissions and hospitalization days | The number of unplanned hospital admissions and hospitalization days in public and private hospitals. | 2-month, 6-month | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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dementia, advance care planning