ACCEPT Study: Advance Care Planning Evaluation in Elderly Patients. A multi-center, prospective study.

Our health care system is under siege- an aging population, patients living longer with chronic illness, and an increasing demand for services at end of life contribute to escalating costs and utilization patterns that are unsustainable. In a recent national survey, more than 80% of respondents were concerned the quality of health care in Canada will decline as a result of increased strain on the health care system as our population gets older. Advance Care Planning (ACP) may offer some assistance with reducing health care costs for older Canadians and yet, at the same time, improving quality of care. ACP is the process by which a person considers options about future health care decisions and identifies their wishes. An advance care plan is a verbal or written instruction describing what kind of care an individual would want (or not want) if they are no longer able to speak for themselves. ACP has been shown to increase the quality of life of dying patients, improve the experience of family members, and decrease health care costs.

Under the leadership of the Canadian Hospice and Palliative Care Association (CHPCA), clinicians, researchers and decision makers have been meeting for the past 3 years to develop a national strategy to implement ACP in Canada. The Calgary Zone of Alberta Health Services and Fraser Health Authority in British Columbia have led the nation in developing and implementing system-wide strategies to increase ACP amongst the population they serve. However, there has been no evaluation of the effectiveness of these efforts from the perspective of patients and families; many questions pertaining to the barriers and facilitators to implementation and the impact of ACP on outcomes in Canada remain. This study is not primarily about whether ACP works, it is more about how best to implement it. Decision-makers in these and other regions need this critical feedback from end users to inform future initiatives designed to improve the quantity and quality of ACP. Canadian researchers have recently developed and validated a satisfaction tool to measure patient and family perspectives on end of life (EOL) communication and decision-making. Building upon collaboration with decision makers and researchers interested in ACP, we have developed this proposal to evaluate ACP in hospitals across Canada with the overall objective of increasing the quality and quantity of ACP efforts specifically, and the overall quality of end of life (EOL) care in general. We propose to conduct a prospective audit of current practice related to ACP in elderly patients at high-risk for dying and their families. We will determine the extent to which these patients and families have engaged in ACP, what barriers and facilitators they perceive, and how satisfied they are with communication and decision making at the EOL. We hypothesize that current rates of ACP in these patients is low and that satisfaction with EOL communication and decision-making is suboptimal. Informed by a baseline evaluation of site strengths, weaknesses and barriers, we propose to develop tailored interventions to enable participating sites to improve their success with ACP during the entire grant cycle. By repeating the audit and feedback cycle annually, we will enable sites to make continuous efforts to improve their performance and be able to evaluate the effect of our audit/feedback/tailored intervention strategy compared to baseline. Additionally, for those patients who have engaged in ACP activities, we can compare their outcomes to those who have not. The insights we gain from evaluating and improving ACP will be disseminated throughout Canada via CHPCA.

If you are interested in participating in the ACCEPT study, please contact study chair, Daren Heyland ( For a complete copy of the protocol, click here .