RESPEKT: Study to implement advance care planning (ACP) in the nursing homes (n/h) of a model region by means of qualifying selected n/h staff to facilitate ACP discussions with residents or their proxies

Prevalence of written advance directives (authored by the resident or, if incapacitated, the legal proxy), in a three-step approach:
1. Presence of an advance directive (yes or no). If an advance directive is present, then the following step is evaluated:
2. Meaningfulness of the advance directive, i.e. it addresses the following scenarios typically relevant for nursing homes in Germany: cardiopulmonary resuscitation; hospital admission for life-sustaining treatment; long-term artificial feeding in dementia, both for the state of current decision-making capacity (if still given), and a possible future decision-making incapacity. If an advance directive is meaningful in that sense, then the following step is evaluated:
3. Validity of the advance directive, defined by a physician's written testimony that the signer (resident or proxy):
3.1. Has currently decision making capacity, and
3.2. Has understood and appreciated the implications of his or her decision

Primary outcomes measured on 30/06/2010.

1. Process quality:
1.1. Presence of a physician's order for emergency situations directed at the nursing staff, clarifying the issue of cardiopulmonary resuscitation (yes or no), of hospital admission, and of any urgent procedures aiming to prolong life.
1.2. Accessibility of advance directives/physician's order from within the nursing ward:
1.2.1. Rate of easily noticeable references to a given advance care planning in the paper or electronic file
1.2.2. Copy of advance directive and/or physician's order is prepared for the case of a transferral to hospital
1.3. Management of advance directives or physician orders' during residents' hospital stays
1.3.1. Copy of AD or physician order is in the hospital file
1.3.2. Treatment limitations stated in physicians' orders brought from the n/h are translated into corresponding written orders by hospital doctors
1.3.3. AD or physician's order is mentioned in discharge letter

2. Outcome quality:
2.1. Treatment:
2.1.1. Incidence of feeding tube insertions, days of artificial feeding, days of parenteral fluid application, as far as congruent with the expressed residents' preferences
2.1.2. Incidence and days of hospital treatments
2.1.3. Incidence of decubital ulcers
2.2. Course before dying:
2.2.1. Location of dying
2.2.2. Number of transferrals to hospital in the 30 (90) days before death
2.2.3. In-hospital (in-ICU) days in the 30 (90) days before death
2.2.4. Rate of index-treatments in the 30 (90) days before death (i.e., CPR, feeding tube insertions, days of artificial feeding, artificial ventilation, pace maker insertions, incidence of general surgery)
2.2.5. Incidence of decubital ulcers in the 30 (90) days before dying
2.3. Perception of the dying process from the perspective of third parties:
2.3.1. Judgment of the dying process from the nursing perspective
2.3.2. Judgment of the dying process from the relative perspective (after-bereavement interview)

3. Analysis of possible confounders:
3.1. Sex
3.2. Age
3.3. Nursing home
3.4. Facilitator

Secondary outcomes measured on 31/07/2010.