Project Overview

Advance care planning (ACP) is a process designed to help people get the medical care that is right for them during future serious illness. ACP supports individuals in understanding and sharing their personal values, life goals, and preferences for future medical care. ACP is especially relevant for frail older adults who may be faced with imminent end-of-life decisions. ACP can improve frail elderly Canadians’ experience during late life, improve the work experience for clinicians, and avoid unwanted and costly aggressive treatments at the end-of-life.

In this CFN Transformative Grant, our experienced team of investigators, international collaborators, knowledge user organizations, and patient advisors will focus on the creation of a multi-faceted suite of tools to improve the uptake and impact of advance care planning for frail elderly Canadians in the primary care, long-term care, and hospital settings. To achieve this aim, we are proposing a transformative program of interventional research within these key care settings in Canada. Candidate interventions for inclusion in this multi-faceted suite of tools include: (1) tools for patients and families to support them through the ACP process, and (2) tools for clinicians to enhance their communication skills.

The key objectives for our program of research are:

1. To develop or refine ACP tools to include in our multi-faceted suite of tools for patients, family members, and clinicians.
2. To evaluate the impact of candidate tools on patient, family, clinician, and health system outcomes
3. To disseminate and implement our multi-faceted suite of ACP tools on a large scale across these care settings in Canada.
4. To improve access to ACP for persons at heightened risk of having their care preferences overlooked (i.e., populations who may be socially marginalized due to geography, ethnicity, religion, etc.)

This research builds on current CFN- and other partner-funded research in the primary care, long-term care, and hospital settings, and will directly address longstanding barriers to engagement in ACP by Canadians. Our research program will provide an evidence base for the effectiveness of various ACP tools and implementation approaches across health care sectors. Other deliverables for our research program will include: building new research capacity (HQP training) within a diverse, multidisciplinary environment; targeted knowledge translation activities; and building new partnerships with stakeholder organizations.

Given resource allocation concerns, it is imperative that these ACP tools and resources are targeted to patients most in need – those with frailty for whom ACP and decision-making about life-sustaining treatments are most relevant. In a synergistic proposal, Dr Paul Hebert and colleagues focus on use of the RAI (Resident Assessment Instrument) as a key strategy to identify patients in diverse care settings who are frail and at high risk of dying. Once identified, this will trigger subsequent interventions, such as ACP (the focus of our proposal) and other medical and social interventions. Our groups will work closely together to create a synergistic research program that will transform the care of frail elderly in Canada.