Implementing a Nurse-led Advance Care Planning (ACP) Intervention in Residential Care Homes

NCT06238063 | Recruiting

• 1 other identifier: UW 22-021
• Study Type: interventional
• Target: 164
• Locations: 1 country
• Sites: 1

Brief Summary

The goal of this cluster randomized controlled trial is to examine the effectiveness of a nurse-led advance care planning (ACP) intervention on improving ACP discussion uptake in residential care homes (RCHs). The main question it aims to answer is: The effectiveness of nurse-led advance care planning (ACP) interventions implemented on eligible residents in residential care homes on improving ACP discussion uptake in this population. Compared to participants in the control group who will only receive usual care with no ACP intervention, residents and their family members in the intervention group will be invited to attend the ICP meeting with ACP discussion. The ACP discussion will be guided by the established protocol, which was developed by the expert panel and delivered by trained nurses.

Conditions

Advanced Care Planning

Outcome Measures

Primary Outcomes (3)

• Change from Baseline in Chart review at post-intervention

  The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.

  baseline and immediately after the intervention

• Change from Baseline in Chart review at 1-year follow-up time point.

  The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.

  1-year follow-up (i.e., 1 year after the launch of the ACP intervention)

• Change from Baseline in Chart review at 2-year follow-up time point.

  The medical records of all RCH residents will be audited at baseline (T0), post-intervention (T1; after the ACP intervention), 1-year follow-up (T2; 1 year after the launch of the ACP intervention at the RCH), and 2-year follow-up (T3; 2 years after the launch of the ACP intervention at the RCH). The following information will be extracted: ACP documentation (primary outcome; i.e., new documentation related to ACP and EOL care); designated surrogate decision-maker; AD completion; and healthcare utilization (i.e., number of inpatient hospitalizations, emergency department visits, intensive care unit admissions and length of stay, mechanical intubation rates and in-hospital cardiopulmonary resuscitation rates during the 6 months before death, place of death). The information specific to ACP intervention will only be extracted in residents who participated in ACP intervention: concordance on EOL preferences ; and concordance between preferred and actual outcomes of EOL care.

  2-year follow-up (i.e., 2 years after the launch of the ACP intervention at the RCH).

Other Outcomes (5)

• Quality about End-of-life Communication (QOC)

  immediately after the intervention and 2 years after the launch of intervention.

• Caregiver quality-of-life (QOL)

  baseline, immediately after the intervention, and 2 years after the launch of intervention.

• Qualitative interviews

  immediately after the intervention and 1 year after the launch of intervention

Study Arms (2)

Intervention

EXPERIMENTAL

The ACP intervention, which was developed by the expert panel, will be delivered by trained nurses in each RCH during a mandatory annual individual care planning (ICP) meeting. Eligible residents and their family members will be invited to attend the ICP meeting with ACP discussion.

Behavioral: Nurse-led Advance Care Planning (ACP) Intervention

Control

NO INTERVENTION

Participants in the control arm will receive usual care with no ACP intervention.

Interventions

Nurse-led Advance Care Planning (ACP) Intervention BEHAVIORAL

An ACP discussion between the participating resident, family members, and the trained nurse will be incorporated into the annual review. The proposed ACP intervention will be divided into three parts (three weekly sessions, 1.5 hours each): 1) preparatory, 2) discussion, and 3) follow-up sessions.

Intervention

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Older Adult (65+)

You may qualify if:

• Eligible participants have to be age 65 or older and be able to communicate in Cantonese or Mandarin.
• Participants will also be invited to identify family members involved in making decisions about their care to participate in the intervention. For residents who have moderate or severe cognitive impairment (as determined by a score of less than 19 in the Hong Kong version of the Montreal Cognitive Assessment), the participation of family members is mandatory.

You may not qualify if:

• They have a moderate or severe significant cognitive impairment but do not have family members, or
• They have prior ACP experience (e.g., AD completed).

Sponsors & Collaborators

• The University of Hong Kong: lead

Study Sites (1)

The University of Hong Kong

Hong Kong, Hong Kong

RECRUITING

Related Publications (1)

• Wang T, Cheung DST, Chu C, Chen J, Lin CC. Evaluation of a train-the-trainer implementation strategy on providers' competency, opportunity and motivation for advance care planning in residential care homes: a mixed-methods study. BMC Geriatr. 2026 Jan 3. doi: 10.1186/s12877-025-06898-2. Online ahead of print.

  PMID: 41484702 DERIVED

MeSH Terms

Interventions

Methods

Intervention Hierarchy (Ancestors)

Investigative Techniques

Study Officials

• Chia-Chin Lin, PhD

  The University of Hong Kong

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Chia-Chin Lin, PhD

CONTACT

39176633; cclin@hku.hk

Tongyao Wang, PhD

CONTACT

39102790; tongyao1@hku.hk

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: SUPPORTIVE CARE
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: March 23, 2023
• First Posted: February 2, 2024
• Study Start: July 1, 2022
• Primary Completion: October 31, 2025
• Study Completion: December 31, 2025
• Last Updated: July 11, 2025

Record last verified: 2025-06

Data Sharing

• IPD Sharing: Will not share

Locations

HK (1)