Advance care planning (ACP) can improve the quality of life of patients with heart failure, especially if it includes follow-up, involves family members and is carried out by trained clinicians working in multidisciplinary teams.
This review summarised the evidence about the effect of ACP on quality of life, compared with usual care, for 2,924 patients in 14 trials. All the participants were adults diagnosed with heart failure, in community, hospital or hospice care.
The study suggests that ACP needs to be carefully timed and take into account patients’ cultural preferences if it is to have a positive effect. Isolated interventions to complete care planning documents may not be enough to improve the quality of life.
Why was this study needed?
Around 200,000 people are newly diagnosed with heart failure each year in the UK. The condition is progressive and eventually fatal, so end of life care is an important issue to address. Advance care planning is often recommended to help patients and their families think about the care they wish to receive at the end of life, before they are unable to express an opinion.
Questions might include their resuscitation preferences, where they would like to be cared for, and discussion about switching off implanted defibrillating pacemakers.
Most research has focused on how well interventions work to ensure people take part in ACP. There is less research about how ACP actually affects people with heart failure. This review aimed to measure the effect of ACP on the quality of life of people with heart failure.
What did this study do?
This systematic review and meta-analysis analysed 14 randomised controlled trials with 2,924 participants. Researchers looked at the effect of ACP on quality of life, patient satisfaction with care and quality of end-of-life communication. One study was UK based but most were from the US.
They defined ACP as interventions which provided a "coordinated and comprehensive approach" to future care and excluded interventions which only looked at decisions around resuscitation. They tried to identify what characterised interventions with larger or smaller effect sizes.
They carried out GRADE assessments of bias, which found the overall quality of evidence to be low or moderate, largely because of the difficulty in blinding patients to the intervention. This could have biased the findings in favour of the intervention.
What did it find?
- ACP moderately improved the quality of life of patients (standardised mean difference [SMD] 0.38, 95% confidence interval [CI] 0.09 to 0.66; 7 studies, 724 participants).
- ACP moderately improved patient satisfaction (SMD 0.39, 95% CI 0.14 to 0.64; 4 studies, 1,290 participants).
- Quality of end of life communication was moderately improved by ACP (SMD 0.29, 95% CI 0.17 to 0.42; 4 studies, 995 patients).
- The ACP interventions which had bigger effect sizes tended to be timed at a significant point in the patient’s journey (such as before hospital discharge), used trained clinicians working in multidisciplinary teams, involved education of patients about their options, included the patient’s family, and had planned follow-up.
What does current guidance say on this issue?
A NICE guideline from 2018 on management of heart failure mentions ACP only in the context of discussion around switching off implanted defibrillating pacemakers. The guideline says benefits and harms of the defibrillator remaining active should be discussed as part of ACP if it is thought the patient is nearing the end of life.
The guideline also says consideration should be given to people working in heart failure to have advanced communication skills training.
What are the implications?
The findings of the study suggest that ACP should be introduced into the care of people with heart failure:
- at a significant milestone in their illness
- with follow-up appointments over a period of time
- with mindfulness about ACP preferences
- with an offer to involve family members
- within the context of a multidisciplinary team.
Advance care planning given as an isolated intervention, without due consideration of these issues, may not be effective. Introducing ACP effectively is likely to involve staff training and planning at a multidisciplinary level.
Citation and Funding
Schichtel M, Wee B, Perera R and Onakpoya I. The effect of advance care planning on heart failure: a systematic review and meta-analysis. J Gen Intern Med. 2019; November 12. doi: 10.1007/s11606-019-05482-w. [Epub ahead of print].
No funding information was provided for this study.
NICE. Chronic heart failure in adults: diagnosis and management. NG106. London: National Institute for Health and Care Excellence; 2018.
Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre