• Jürgen In der Schmitten, Katharina Lex, Christine Mellert, Sonja Rothärmel, Karl Wegscheider, and Georg Marckmann.
• Department of General Practice, Düsseldorf University, University Hospital, Institute for Patient Safety, Rheinische Friedrich-Wilhelms-Universität Bonn, Faculty of Social Work, Catholic University of Eichstätt-Ingolstadt, Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Institute of Ethics, History and Theory of Medicine at the Ludwig Maximilians University Munich.
• Dtsch Arztebl Int. 2014 Jan 24; 111 (4): 505750-7.

BackgroundAdvance Care Planning (ACP) is a systematic approach to ensure that effective advance directives (ADs) are developed and respected. We studied the effects of implementing a regional ACP program in Germany.MethodsIn a prospective, inter-regionally controlled trial focusing on nursing homes (n/hs), we compared the number, relevance and validity of new ADs completed in the intervention region versus the control region. Intervention n/h residents and their families were offered professional facilitation including standardized documentation.ResultsData from 136 residents of three intervention n/hs were compared with data from 439 residents of 10 control n/hs over a study period of 16.5 months. In the intervention region, 49 (36.0%) participating residents completed a new AD over the period of the study, compared to 18 (4.1%) in the control region; these ADs included 30 ADs by proxy in the intervention region versus 10 in the control region. Proxies were designated in 94.7% versus 50.0% of cases, the AD was signed by a physician in 93.9% versus 16.7%, and an emergency order was included in 98.0% versus 44.4%. Resuscitation status was addressed in 95.9% versus 38.9% of cases (p<0.01 for all of the differences mentioned above). In the intervention region, new ADs were preceded by an average of 2.5 facilitated conversations (range, 2–5) with a mean total duration of 100 minutes (range, 60–240 minutes).ConclusionThe implementation of an ACP program in German nursing homes led, much more frequently than previously reported, to the creation of advance directives with potential relevance to medical decision-making. Future research should assess the effect of such programs on clinical and structural outcomes.

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