Advance care planning practices in the nursing home setting: A secondary analysis.

Background and objectives Advance care planning is intended to support resident's preferences regarding health decisions, even when they can no longer participate. Little is known about the power discourses influencing how residents, family-members, and healthcare workers engage in advance care planning and how advance care directives are used if conflict arises. A large critical ethnographic study was conducted exploring decision making when a resident's health deteriorates in the nursing home setting. Advance care planning practices were not the focus of the original study, but the richness of the data warranted further exploration. A new research question was developed to inform a secondary analysis: How does advance care planning influence the relationship between resident values and clinical expertise when determining a direction of care at the time of a resident deterioration? Research design and methods A secondary analysis of data from an ethnographic study involving 184 hours of participatory observation, 40 semi-structured interviews and advance care planning policies and document review undertaken in in two nursing homes in Melbourne, Australia. Results Advance care planning may result in inaccurate documentation of residents' preferences and devalue clinical decision-making and communication with residents and family-members at the time of deterioration. Discussion and implications Advance care planning may contribute towards a reductionist approach to decision-making. There is an urgent need for the development of evidence-based policy and legislation to support residents, families, and healthcare workers to make appropriate decisions, including withholding invasive treatment when a resident deteriorates.