# Advance Care Planning and Frailty in Nursing Homes: Feasibility and Acceptance of a Stepwise, Long-Term Care, Structured Model

## TL;DR

This study shows that advance care planning is widely accepted in nursing homes and helps align care with residents' preferences, especially for those with higher frailty.

## Contribution

A structured, stepwise model of ACP was evaluated for feasibility and acceptance in nursing homes, revealing strong uptake and preference patterns linked to frailty.

## Key findings

- 93.7% of new nursing home residents accepted ACP, indicating high feasibility.
- Frailty levels correlated with care preferences, with higher frailty associated with stronger preferences for do-not-resuscitate orders and avoiding hospital transfers.
- ACP sessions averaged 139 minutes across 3–4 sessions, suggesting a manageable process for implementation.

## Abstract

Background/Objectives: Population aging in Europe presents significant healthcare, economic, and social challenges, particularly in the care of individuals with chronic diseases and frailty. Advance Care Planning (ACP) fosters patient autonomy and aligns end-of-life care with individual preferences. This study aimed to evaluate the acceptability and feasibility of an ACP model in nursing homes. Secondary objectives included exploring clinical characteristics of participants and assessing how frailty is associated with residents’ care goals and preferences. Methods: A prospective observational study was conducted among long-term residents of a Spanish nursing home in 2023. ACP was offered to all new permanent residents, with outcomes assessed through quarterly follow-ups. Acceptance rates, care preferences, and resident satisfaction were primary measures. Clinical data, frailty, functional status, cognitive assessments, and nutritional status were analyzed. The model of ACP is structured into three progressive levels: (1) identification of patients’ values, preferences, and global goals of care; (2) decision-making regarding specific clinical interventions in acute situations; and (3) end-of-life care preferences, including preferred place of death, desired companionship, and comfort-focused measures. Results: From 79 new residents admitted, 93.7% accepted ACP. The process required an average of 139 min to complete, distributed over 3–4 sessions. The main documented preferences included do-not-resuscitate orders (CPR) (79%), hospital transfer decisions (50%), and other individualized care choices. When stratified by frailty level, which was categorized as low, moderate, or high—we observed a clear gradient in care preferences. CPR preference increased from 59.3% (Low) to 87.5% (Moderate) and 95.2% (High). Preference to avoid hospital transfer rose from 22.2% to 50.0% and 85.7%, respectively. Avoidance of instrumentalization increased from 56.2% to 85.0% and 95.0%. Conclusions: ACP in nursing homes is highly acceptable and feasible, with benefits in aligning care with patient preferences and enhancing satisfaction.