Purpose: The purpose of this systematic review and meta-analysis was to investigate the effects of advance care planning on end-of-life decision-making. Methods: Databases including RISS, KISS, KMbase, KoreaMed, PubMed (MEDLINE), Embase, and CINAHL were searched for studies that examined the effects...
Purpose: The purpose of this systematic review and meta-analysis was to investigate the effects of advance care planning on end-of-life decision-making. Methods: Databases including RISS, KISS, KMbase, KoreaMed, PubMed (MEDLINE), Embase, and CINAHL were searched for studies that examined the effects of advance care planning interventions. The inclusion criteria were original studies in English or Korean; adults ≥18 years of age (population); advance care planning (intervention); completion of advance directives (AD) or advance care planning (ACP) (outcomes); and randomized or non-randomized controlled trials (RCTs and non-RCTs, respectively) (design). Study quality was measured using the checklists of the Joanna Briggs Institute. Meta-analyses were conducted with the Comprehensive Meta-Analysis program. Results: Nine RCTs and nine non-RCTs were selected for the final analysis. The effect sizes (ES) of the outcome variables in nine RCTs were meta-analyzed, and found to range from 0.142 to 0.496 for the completion of AD and ACP (ES=0.496, 95% CI: 0.157~0.836), discussion of end-of-life care (ES=0.429, 95% CI: -0.027~0.885), quality of communication (ES=0.413, 95% CI: 0.008~0.818), decisional conflict (ES=0.349, 95% CI: -0.059~0.758), and congruence between preferences for care and delivered care (ES=0.142, 95% CI: -0.267~0.552). Conclusion: ACP interventions had a positive effect on the completion of AD and ACP. To apply AD or ACP in Korea, it is necessary to develop ACP interventions that reflect aspects of Korean culture.
Purpose: The purpose of this systematic review and meta-analysis was to investigate the effects of advance care planning on end-of-life decision-making. Methods: Databases including RISS, KISS, KMbase, KoreaMed, PubMed (MEDLINE), Embase, and CINAHL were searched for studies that examined the effects of advance care planning interventions. The inclusion criteria were original studies in English or Korean; adults ≥18 years of age (population); advance care planning (intervention); completion of advance directives (AD) or advance care planning (ACP) (outcomes); and randomized or non-randomized controlled trials (RCTs and non-RCTs, respectively) (design). Study quality was measured using the checklists of the Joanna Briggs Institute. Meta-analyses were conducted with the Comprehensive Meta-Analysis program. Results: Nine RCTs and nine non-RCTs were selected for the final analysis. The effect sizes (ES) of the outcome variables in nine RCTs were meta-analyzed, and found to range from 0.142 to 0.496 for the completion of AD and ACP (ES=0.496, 95% CI: 0.157~0.836), discussion of end-of-life care (ES=0.429, 95% CI: -0.027~0.885), quality of communication (ES=0.413, 95% CI: 0.008~0.818), decisional conflict (ES=0.349, 95% CI: -0.059~0.758), and congruence between preferences for care and delivered care (ES=0.142, 95% CI: -0.267~0.552). Conclusion: ACP interventions had a positive effect on the completion of AD and ACP. To apply AD or ACP in Korea, it is necessary to develop ACP interventions that reflect aspects of Korean culture.
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문제 정의
The purpose of this study was to analyze the effects of intervention programs developed to help decision-making related to end-of-life care in Korea and abroad through the preparation of advance care planning. In this study, we analyze existing intervention programs that aim to promote the completion of advance directives, and thereby will provide a foundation for establishing effective intervention programs for Korean patients at the end of life.
The “Respecting choices” program, which was designed to promote creating advance care planning [17,18], helps patients better understand advance care planning through interviews and takes into account their goals of end-of-life care. The program also encourages patients to communicate with their loved ones about their desires and to put the discussions in writing. A meta-analysis of the effects of the “Respecting choices” program reported that the program contributed to better alignment of the opinions of patients and their representatives [17].
The purpose of this study was to analyze the effects of intervention programs developed to help decision-making related to end-of-life care in Korea and abroad through the preparation of advance care planning. In this study, we analyze existing intervention programs that aim to promote the completion of advance directives, and thereby will provide a foundation for establishing effective intervention programs for Korean patients at the end of life.
This study is a systemic literature review and meta-analysis of the effects of programs aiming to assist decision-making regarding end-of-life care on advance care planning.
제안 방법
All of the programs used in these studies focused on communication with the aim of enhancing patients’ ability to make decisions.
During the literature search, the researchers evaluated the appropriateness of each other’s search strategy through a preliminary search.
Effect sizes were calculated using the standardized mean difference (SMD) to standardize the inconsistent results reported by the studies. An effect size of 0.
The outcome variables of the studies meeting the selection criteria of this study were the completion of advance directives and advance care plans, discussion of end-of-life care, quality of communication, decisional conflict, the patient’s legal representative’s confidence in decision-making, congruence regarding preferred care between the patient and the patient’ s legal representative, and congruence between preferences for care and delivered care.
The outcome variables of the studies were required to meet the selection criteria of this study, including the completion of advance directives and advance care plans, discussion of endof-life care, quality of communication, decisional conflict, the patient’s legal representative’s confidence in decision-making, and congruence regarding preferred care between the patient and the patient’s legal representative.
Non-intervention groups of patients who did not participate in these programs or received usual care were selected as comparison groups. The primary outcome variables of the interventions were completion of advance directives and advance care planning, discussion of end-of-life care, and quality of communication. Secondary outcome variables were decisional conflict, confidence of the patient’s legal representative in decision-making, congruence between the patient and the patient’s legal representative regarding the preferred treatment, and congruence between preferences for care and delivered care.
Studies were searched using the PICOS approach. The two researchers discussed and agreed on the search strategy and confirmed their congruence through a preliminary search before performing the actual search. The researchers independently searched all of the databases.
This study analyzed effect sizes through a systematic review and meta-analysis of previous experimental research to understand how intervention programs developed to assist in decision-making for end-of-life care affected advance care planning. Eighteen studies were finally selected for the analysis after reviewing a total of 4,668 studies found in the initial search.
This study assessed the methodological quality of the studies using the JBI appraisal tools [20], which deal with potential bias broadly, ranging from study design to implementation and analysis. The tools contain similar items to version 2 of the risk of bias tool by the Cochrane Group.
The Checklist for Quasi-Experimental Studies (non-randomized experimental studies) was used to appraise non-randomized studies. This tool comprises nine items, including a clear distinction of cause and effect, similarity of participants, control of participants, existence of a control group, measurement of outcomes before and after the intervention/exposure, adequate treatment of completion of follow-up and difference between groups, identical measurement of outcomes, reliability of measurements, and appropriateness of statistical analysis. Each item was rated as “yes”, “no”, “unclear”, or “not applicable”.
Randomized controlled trials (RCTs) were evaluated using the Checklist for Randomized Controlled Trials. This tool contains 13 items, including randomization used for assignment of participants, concealment of allocation to treatment groups, similarity of participants, participant blinding, treatment provider blinding, assessor blinding, identical treatment other than the intervention of interest, adequate treatment of completion of followup and difference between groups, analysis of participants in the randomized groups, identical measurement of outcomes, reliability of measurements, appropriateness of statistical analysis, and appropriateness of trial design. The Checklist for Quasi-Experimental Studies (non-randomized experimental studies) was used to appraise non-randomized studies.
대상 데이터
An analysis of the characteristics of the included RCTs (Table 3) showed that the studies were published between 2002 and 2018, including three that were published before 2010. The patients’ conditions included chronic obstructive pulmonary disease, congestive heart failure, cancer, dialysis, and severe dementia, and the participants included community-dwelling patients, elderly patients, and homeless persons.
This study analyzed effect sizes through a systematic review and meta-analysis of previous experimental research to understand how intervention programs developed to assist in decision-making for end-of-life care affected advance care planning. Eighteen studies were finally selected for the analysis after reviewing a total of 4,668 studies found in the initial search.
The databases used to search the international literature were PubMed (MEDLINE), Embase, and CINAHL, while RISS, KISS, KMbase, and KoreaMed were used to search the Korean literature. Studies were searched using the PICOS approach.
The patients’ conditions included chronic obstructive pulmonary disease, congestive heart failure, cancer, dialysis, and severe dementia, and the participants included community-dwelling patients, elderly patients, and homeless persons. The number of participants in each study was between 32 and 376.
The participants’ illnesses included chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, and the participants were lowincome older adults, long-term care residents, and community dwellers.
The patients’ conditions included chronic obstructive pulmonary disease, congestive heart failure, cancer, dialysis, and severe dementia, and the participants included community-dwelling patients, elderly patients, and homeless persons.
The researchers independently reviewed the literature at each stage of the literature selection process and selected the final list through discussion. The search results found a total of 1,293 Korean studies (362 from RISS, 102 from KISS, 124 from KMbase, and 705 from KoreaMed) and 3,334 international studies (2,574 from PubMed [MEDLINE], 243 from Embase, and 517 from CINAHL). The total number of domestic and overseas studies was 4,668 after adding 42 manually searched studies.
이론/모형
A fixed-effects model is appropriate when there is minimal heterogeneity in the effect size, while a random-effects model is suitable for high heterogeneity. A fixed-effects model was applied in this study, as low heterogeneity was found for all variables, with a P＞0.10.
The databases used to search the international literature were PubMed (MEDLINE), Embase, and CINAHL, while RISS, KISS, KMbase, and KoreaMed were used to search the Korean literature. Studies were searched using the PICOS approach. The two researchers discussed and agreed on the search strategy and confirmed their congruence through a preliminary search before performing the actual search.
Publication bias occurs when the outcome of a study influences the decision of whether to publish it [23]. The funnel plot and trim-and-fill methods were used to check for publication bias. The funnel plot method has long been used to evaluate the possibility of missing outcomes in meta-analyses [23], using a dispersion chart with the x-axis displaying the effect size and the y-axis displaying the sample size [22].
성능/효과
The meta-analysis showed that advance care planning interventions had significant effects on the completion of advance directives and advance care planning, as well as communication quality, but no significant effect on discussions on endof-life care, decisional conflict, or congruence in preferred care between patients and their legal representatives. The outcome variable with the largest effect size was completion of advance directives and advance care plans.
The JBI quality appraisal tool does not suggest criteria for evaluating the overall quality of studies; instead, it only allows an item-by-item evaluation. Through discussions, the researchers established criteria for selecting the final studies; specifically, studies with a randomized control group were only included if at least nine out of 13 items (70%) were assured of quality, and non-randomized experimental studies were only included when at least six out of nine items (roughly 70%) were assured of quality. The quality of the 27 studies initially included in the systematic review was assessed.
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