Intervention synergy
| Study OR (95% CI) | Content of the most effective interventions Description according to EPOC | Timing of the intervention | Synergy |
| Rubin et al
35 61.58 (15.11 to 250.96) |
Physicians received a patient visit and were prompted (patient-mediated) by the patient to talk about EOL issues. The provision and completion of a durable power of attorney form was prompted by the patient visit Patients were educated in how to prompt clinicians to engage with ACP and complete a durable power of attorney. They were offered telephone support throughout the study. Patients were sent a cover letter, an educational brochure with treatment options and a durable power of attorney form | Patients were educated in ACP after a recent hospitalisation at a time when their medical condition was stable | Physicians responded to educated patients who had the motivation and skills to initiate discussions about their ACP preferences. Additionally, patients were given the opportunity and time to clarify their wishes before the completion of an ACP document |
| Nicolasora et al
41 18.55 (2.38 to 144.37) |
Physicians were trained in using a script (training) from which to read detailed information about ACP (education). Patients prompted (patient-mediated) clinicians to talk about ACP Patients were educated in the purpose of ACP and trained how to communicate their EOLC preferences with their clinician. They could reflect on how the information about ACP applied to their own values | At the point of admission to hospital, patients were asked by the admitting staff about their EOL wishes and the completion of an ACP document | The concurrent arrangement of targeting physicians and patients may have increased physician–patient dialogue, a clarification of EOL preferences and a greater proportion of completed ACPs. The training of patients and clinicians in the intervention group may have increased levels of motivation and skills to address ACP |
| Detering et al
32 14.84 (3.89 to 56.70) |
Physicians received a patient visit (patient-mediated) who prompted an ACP conversation Patients received education from an ACP facilitator using the Respecting Patient Choices model about the purpose of ACP. They were educated on how to identify a surrogate decision-maker and how to identify EOLC choices. Typically, the facilitator met with patients and family members on three occasions before discharge to achieve an ACP | Before hospital discharge, patients and family members were asked by a trained facilitator (nurse or allied health professional) whether they would like to engage with ACP | Both, patients and facilitators, were trained in identifying and communicating EOL issues and ACP preferences. Patients and families were given the time and the opportunity to think about their choices leading to better shared decision-making and ACP completion |
| Heiman et al
28 5.90 (1.58 to 22.00) |
Physicians received computer-generated reminders including an ACP template (reminder system), training in how to use the ACP template (educational meeting) and education on the purpose of ACP Patients received educational brochures on ACP, a set of ACP forms. They were encouraged to ask their clinician about ACP | Physicians received ACP computer reminders 1 day prior to the patient visit Patients received ACP education 6 weeks prior to their scheduled routine appointment | Physician–patient interaction and ACP completion may have been improved by simultaneously targeting physicians and patients with reminders and training in communicating EOL/ACP issues. The content and electronic format of the ACP reminder made it easy for the clinician to identify relevant issues that needed to be covered |
| Study OR (95% CI) | Content of the least effective interventions Description according to EPOC and BCTTv1 | Timing of the intervention | Synergy |
| Gade et al
42 1.66 (1.09 to 2.52) |
Physicians received support from an interdisciplinary palliative care consultative service (IPCS) in the management of patients with HF. Patients were only the passive recipients of information. While members of the IPCS team met with patients and family members on an as-required basis, patients were not educated in identifying their EOLC preferences or trained in how to talk to their clinicians about ACP | After admission to hospital, patients were approached to document their EOLC preferences | A lack of interaction between physicians and patients was in part due to the omission of training and supporting patients to proactively talk to their clinicians about ACP. The comparatively small effect size of this rather costly intervention involving many clinicians was remarkable |
| Heffner and Barbieri37 1.56 (0.95 to 2.56) |
Physicians were prompted by their patients to discuss ACP. Clinicians did not receive any training or support in how to address EOL issues Patients received only printed material on the purposes of ACP and were encouraged to talk to their clinicians about it. Patients did not receive any training in how to talk to their clinicians. Only 2% of patients in the intervention group and 12% in the control group suffered from CHF NYHA Class III and IV | The majority of patients was at an early stage in their HF disease trajectory. The intervention was delivered in the context of a cardiovascular rehabilitation programme | Only the minority of patients suffered from end-stage CHF. These patients might have been less motivated to talk to their clinician about ACP since the relevance seemed less obvious. Additionally, neither patients nor physicians received any training in talking about or completing an ACP |
| Reilly et al
40 1.19 (0.46 to 3.04) |
Physicians received only printed material in form of a cover letter, a brochure explaining an advance directive and the New York State healthcare proxy form. No additional support was offered Patients received the same printed material about advance directives. The cover letter encouraged patients to complete the form before meeting their clinician. Patients did not receive any further education, training or support in filling in the form or identifying their care preferences | Patients who were recently discharged from hospital were sent the educational material and a healthcare proxy form | Patients were expected to complete the form on their own before attending their next outpatient appointment with their clinician. Physicians lacked any training in engaging with ACP. A lack of support for both, physicians and patients, may have resulted in a low level of doctor–patient interaction and ACP completion |
ACP, advance care planning; BCCTTv1,Behaviour Change Techniques Taxonomy Version 1; CHF, congestive heart failure; EOL, end-of-life; EOLC, end-of-life care; EPOC, Cochrane Effective Practice and Organisation of Care Group; NYHA, New York Heart Association.