RESUMO
OBJECTIVE: To provide an overview of the current state of research of advance care planning (ACP), highlighting most studied topics, publication time, quality of studies and reported outcomes, and to identify gaps to improve ACP receptivity, utilization, implementation, and outcomes. METHOD: Cochrane methodology for conducting overviews of systematic reviews. Study quality was assessed using a modified version of the Assessing the Methodological Quality of Systematic Reviews tool. The following databases were searched from inception to April 2017: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE. Searches were supplemented with gray literature and manual searches. RESULT: Eighty systematic reviews, covering 1,662 single articles, show that ACP-related research focuses on nine main topics: (1) ACP as part of end-of-life or palliative care interventions, (2) care decision-making; (3) communication strategies; (4) factors influencing ACP implementation; (5) ACP for specific patient groups, (6) ACP effectiveness; (7) ACP experiences; (8) ACP cost; and (9) ACP outcome measures. The majority of this research was published since 2014, its quality ranges from moderate to low, and reports on documentation, concordance, preferences, and resource utilization outcomes. SIGNIFICANCE OF RESULTS: Despite the surge of ACP research, there are major knowledge gaps about ACP initiation, timeliness, optimal content, and impact because of the low quality and fragmentation of the available evidence. Research has mostly focused on discrete aspects within ACP instead of using a holistic evaluative approach that takes into account its intricate working mechanisms, the effects of systems and contexts, and the impacts on multilevel stakeholders. Higher quality studies and innovative interventions are needed to develop effective ACP programs and address research gaps.
RESUMO
BACKGROUND: Advance care planning (ACP) involves important decision making about future medical needs. The high-volume and disparate nature of ACP research makes it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians. AIM: The aim of this study was to synthesize ACP research evidence and identify relevant contextual elements, program features, implementation principles, and impacted outcomes to inform policy and practice. DESIGN: An overview of systematic reviews using the Cochrane Handbook of Systematic Reviews of Interventions was performed. Study quality was assessed using a modified version of the AMSTAR (A MeaSurement Tool to Assess Reviews) tool. DATA SOURCES: MEDLINE, EBM Reviews, Cochrane Reviews, CINAHL, Global Health, PsycINFO, and EMBASE were searched for ACP-related research from inception of each database to April 2017. Searches were supplemented with gray literature and manual searches. Eighty systematic reviews, covering over 1660 original articles, were included in the analysis. RESULTS: Legislations, institutional policies, and cultural factors influence ACP development. Positive perceptions toward ACP do not necessarily translate into more end-of-life conversations. Many factors related to patients' and providers' attitudes, and perceptions toward life and mortality influence ACP implementation, decision making, and completion. Limited, low-quality evidence points to several ACP benefits, such as improved end-of-life communication, documentation of care preferences, dying in preferred place, and health care savings. Recurring features that make ACP programs effective include repeated and interactive discussion sessions, decision aids, and interventions targeting multiple stakeholders. CONCLUSIONS: Preliminary evidence highlights several elements that influence the ACP process and provides a variety of features that could support successful, effective, and sustainable ACP implementation. However, this evidence is compartmentalized and limited. Further studies evaluating ACP as a unified program and assessing the impact of ACP for different populations, settings, and contexts are needed to develop programs that are able to unleash ACP's full potential.