Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons

Abstract Background Advance care planning (ACP) involves important decision-making about future medical needs. The high volume and disparate nature of ACP research make it difficult to grasp the evidence and derive clear policy lessons for policymakers and clinicians. Aim To synthesise 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 grey literature and manual searches. Eighty systematic reviews, covering over 1,660 original articles, were included in the analysis. Results Legislations, institutional policies and cultural factors influence ACP development. Positive perceptions towards ACP do not necessarily translate into more end-of-life (EOL) 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 EOL communication, documentation of care preferences, dying in preferred place, and healthcare savings. Recurring features that make ACP programmes 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 programmes able to unleash ACP's full potential.