gms | German Medical Science

Background: Advance care planning (ACP) aligns health care decision with patients’ values and wishes. During the Covid-19 pandemic, emergency referrals from nursing homes to hospitals were common. Contact restrictions and the rapid progression of infections posed barriers to facilitated ACP procedures. Short forms of ACP documentation were developed to fill the gap.

Research aim/Questions: How did stakeholders experience health care decision-making according to the patients’ preferences in nursing homes during the first and second wave of the Covid-19 Pandemic in Germany, especially regarding hospitalisation in emergencies? Were short forms of ACP documentation considered as helpful?

Methods: Qualitative study with semi-structured telephone interviews, conducted between Feb–Aug 2021. Intensity sampling and maximum variation sampling to recruit study participants. Questions based on an interview guide, using a deliberative interview style, which highlights the co-construction of knowledge. Analysis followed the reflexive thematic analysis framework, using a mixed deductive/inductive approach to identify themes. Categories based on the exploration of decision-making, professional roles, and experience with ACP.

Results: Study participants (n=12 physicians; n=10 nurses; n=3 nursing home directors; n=3 ACP facilitators; n=3 residents; n=6 relatives; n=5 others) were between 20–40 yrs (n=6), 41-60 yrs (n=24), 61–80 yrs (n=8) and over 80 yrs (n=4) old. 80% of the professionals stated more than 10 yrs work experience. Overall 74%, but most nurses, residents and relatives were female. The pandemic situation led to insecurity, i.e. questioning the applicability of existing ACP documents, fears of restricted access to hospital resources and/or hasty hospital admissions, in particular during the first wave. Perceptions and use of structured ACP documents and processes varied, only one physician used a short form regularly. Based on categories, capture of two themes: “passing on responsibility”, fuelled by insecurity, stress and anxiety evoked by the pandemic, in contrast to “assuming responsibility”, related to caring, adaptability and communication.

Discussion: Multiple incidences of passing on responsibility e.g. from nursing homes to hospitals, from relatives to physicians, from physicians to hospitals. Assuming responsibility in the sense of respecting patients’ treatment choices resonated with the capacity to adapt to change, to reframe care, and to increase communication. Nursing homes with implemented ACP utilized associated routines and resources to overcome insecurity and adapt to the pandemic situation.

Practical Implications: The Covid-19 pandemic created insecurity and contributed to hasty hospital admissions in emergencies. (Re-)assuming responsibility for care aligned to patients’ wishes was facilitated when ACP was implemented in nursing homes prior to the pandemic.

Funding: Einzelförderung (BMG, DRV, BMBF, DFG, etc); 01KI20505