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Advance Care Plans in UK care home residents: a service evaluation using a stepped wedge design

Garden, Gill; Usman, Adeela; Readman, Donna; Storey, Lesley; Wilkinson, Lindsey; Wilson, Graham; Dening, Tom; Gordon, Adam L; Gladman, John

Advance Care Plans in UK care home residents: a service evaluation using a stepped wedge design Thumbnail


Gill Garden

Donna Readman

Lesley Storey

Lindsey Wilkinson

Graham Wilson

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Clinical Professor in Dementia Research

Professor of The Care of Older People

John Gladman


Advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation.
A service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP; and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days.
15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished. 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95%CI 1.1-1.6, p<0.001). Hospital admission rates and bed occupancy did not differ after implementation.
79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Further research should consider how to enlist the support of these homes. Hospital admissions were not reduced and may not be an appropriate outcome metric for ACP in care homes.


Garden, G., Usman, A., Readman, D., Storey, L., Wilkinson, L., Wilson, G., …Gladman, J. (2022). Advance Care Plans in UK care home residents: a service evaluation using a stepped wedge design. Age and Ageing, 51(3), Article afac069.

Journal Article Type Article
Acceptance Date Feb 14, 2022
Online Publication Date Mar 29, 2022
Publication Date 2022-03
Deposit Date Feb 24, 2022
Publicly Available Date Apr 7, 2022
Journal Age and Ageing
Print ISSN 0002-0729
Electronic ISSN 1468-2834
Publisher Oxford University Press
Peer Reviewed Peer Reviewed
Volume 51
Issue 3
Article Number afac069
Keywords Keys words: Advance Care Plans; Care Home residents; Hospital Admissions
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