• Jenny T van der Steen, Mirjam C van Soest-Poortvliet, Meertje Hallie-Heierman, Bregje D Onwuteaka-Philipsen, Luc Deliens, Marike E de Boer, Lieve Van den Block, Nicole van Uden, Cees M P M Hertogh, and Henrica C W de Vet.
• Department of General Practice & Elderly Care Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
• J. Alzheimers Dis. 2014 Jan 1; 40 (3): 743-57.

BackgroundPlanning ahead may be particularly relevant in dementia considering patients' cognitive decline and difficulty to predict the course of the dementia.ObjectiveTo identify factors associated with initiation of advance care planning (ACP) regarding end-of-life issues in dementia.MethodsSystematic review of the PubMed, Embase, Cinahl, Psychinfo, and Cochrane databases until January 2013. We included articles reporting on empirical research, identifying factors related to initiation of ACP defined as starting a discussion, starting the decision making, or having a documented patient-written advance directive.ResultsOf 4,647 unique articles, we assessed 178 as full-texts, and included 33. Most designs (64%) were qualitative; 42% limited to moderate to severe, and 6% to mild to moderate stages. Perspectives varied: family (33%), professional caregivers (24%), patient (15%), or multiple (27%). A variety of factors with complex interplay was involved in initiating ACP. Family factors dominated, with family's initiative or lack of it, and willingness or reluctance to engage in initiating ACP identified in a series of studies. Further, professional caregivers' initiative or lack of it and patient's health status were important factors that facilitated or hindered initiating ACP. Ethnic minority status of those involved and family distance may be barriers. Continuity of care and health care system factors also affected initiating of ACP.ConclusionProfessional caregivers may initiate ACP early if strategies carefully consider timing and family and patient receptiveness or reluctance, and are family and patient-centered. Interventions should address the complexity of interrelated system and personal factors affecting initiation of ACP.

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