Objectives To explore how the COVID-19 pandemic impacted communication around Advanced Care Planning (ACP). We sought to identify the barriers and enablers of ACP communication given the global crisis involving a previously-unknown, serious infection potentially leading to a surge in overtreatment.
Methods We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence. We searched PUBMED database to April 2021 and included all studies that focussed on ACP during COVID-19. Non-English articles were excluded. Titles and abstracts were screened independently by two team members and full-texts selected by one author and reviewed by another. Quality was not appraised and risk-of-bias not formally conducted due to the rapid nature of this review. Studies were categorised for design and common themes were identified.
Results From an original 323 abstracts screened, 74 articles were included in this rapid review. The majority were commentary articles (n=39) and the rest were a mix of primary research studies (n=21) and reviews/guidelines (n=14). Most of the articles derived from the USA (n=49), followed by the UK (n=10), with other countries including India (n=3), Taiwan (n=2), Australia (n=2). The population settings included hospitals, outpatient services, residential aged care and community, indicating the widespread interest in ACP across all aspects of society during COVID-19. The main enablers of ACP communication identified included online tools and availability of telehealth. The development of new online tools and workshops encouraged community engagement with ACP during the COVID-19 pandemic. The expansion of telehealth services facilitated communication between patients, their families and physicians, relating to clinical condition, goals of care and treatment options. This allowed them to share decision-making in the setting of social distancing and visitor restrictions during the pandemic.
Barriers to ACP communication during COVID-19 were more commonly described. Communication was made difficult by the clinical uncertainty around COVID-19, rapid patient deterioration and varied patient responses to treatment, often resulting in delayed ACP discussions. Complex medical jargon and complicated ACP forms also hindered ACP discussions during the pandemic. ACP uptake was shown to be lower in ethnic minorities and groups with lower socioeconomic status, likely due to language barriers, reduced familiarity with the health system and cultural reluctance to discuss death. Clinicians also experienced difficulties communicating about ACP, stemming from low levels of medical education in palliative care/end-of-life planning. Clinicians were reluctant to initiate ACP conversations, fearing they would extinguish hope of recovery. Shortage of personal protective equipment, visitor restrictions, clinician fatigue and high workload were further barriers to effective ACP communication.
Conclusions Effective communication around ACP during the pandemic, despite the challenges discussed, was found to facilitate end-of-life care in accordance with patient’s wishes, reduce anxiety and depression of bereaved relatives, and potentially prevent unwanted aggressive treatments, unnecessary hospital admissions and long periods of self-isolation. Recommendations to standardise ACP tools, engage a multi-disciplinary team to conduct ACP and increase ACP education for the community and clinicians will serve to further drive ACP conversations at the individual, local and international levels.
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