This study aims to evaluate the effectiveness of a motivational interviewing (MI) intervention in enhancing advance care planning (ACP) among older adults who have visited the Emergency Room (ER) in the past six months and their family caregivers. The main question it aims to answer is: The effectiveness of the MI-based ACP intervention implemented within six months of an ER visit on improving older adults' advance directives (AD) completion rate.
Compared to participants in the control group who will only receive a self-education booklet, participants in the intervention group will receive a motivational interview educational intervention to see the effectiveness of an MI-based ACP intervention implemented within six months following an emergency room visit regarding the completion of AD for older adults.
Aged 65 or older
At least one episode of ER visit in the last six months
Has a family caregiver to be present during the intervention
Able to communicate in Chinese
Has completion of an AD
Moderate to severe cognitive impairment or diagnosis of dementia, as identified in health records
Communication problems (e.g., deafness or aphasia)
Aged 18 or above
Parallel
Dyadic MI-ACP intervention
BehavioralMotivational Interviewing on Advance Care Planning Intervention: Dyads of older adults and family caregivers will receive three MI-based ACP counselling sessions: (1) a preparatory session, (2) motivation session, and (3) planning session. The preparatory session will take 10-15 minutes, and the following two sessions in weeks 2 and 3 will last 30-45 minutes each. Before each session, the nurse interventionist will first assess the dyad's readiness to engage in ACP based on the state of change algorithm. Participants who have never thought about ACP will be in the pre-contemplation state, those who are willing to discuss EOL care and preferences to be in the contemplation state, those ready to talk about EOL planning to be in the preparation state, and those in the action state have a confirmed action plan on signing up their ADs. Readiness-based ACP goals will be established, and state-matched MI counseling will be customized for each participant.
Elderly alone MI-ACP
BehavioralOlder adults in this arm will receive an MI-based education intervention our team developed.
Older adults' readiness for ACP
Older adults' readiness for ACP (primary outcome) will be measured by the readiness subscales of the Advance Care Planning Engagement Survey (ACPES), which comprises 6 items rated on a 5-point Likert scale, ranging from 1 (worst outcome) to 5 (best outcome). A higher score indicates a higher readiness for ACP. It assesses an individual's readiness to sign official papers for health decision delegates and ADs and readiness to talk with family and physicians about EOL care, and has been validated in Hong Kong.
Family caregivers' readiness for ACP
Family caregivers' readiness for ACP will be measured by the researcher-developed family caregivers' ACP engagement survey (FACP-10), which consists of 10 items rated on a 5-point Likert scale, ranging from 1 (worst outcome) to 5 (best outcome). A Higher score indicates a higher readiness for ACP. The survey assesses family caregivers' self-reported levels of ACP knowledge, readiness to discuss ACP with a loved one, self-efficacy in initiating ACP conversations with a loved one and barriers to such initiation, and emotional perceptions of and attitudes toward ACP, as well as whether having the necessary communication tools for ACP conversations. We developed the instrument based on the key domains reported in ACPES and the constructs identified in a systematic review of family caregivers' roles in ACP. Our pilot data demonstrated adequate reliability of the scale in Hong Kong family caregivers.
Older adults' emotional perception of ACP
Older adults' emotional perception of ACP will be measured by the 3 item self-efficacy subscale (SE-3) of the ACPES on a 5-point Likert scale, ranging from 1 (worst outcome) to 5 (best outcome), with higher scores indicating greater confidence about participating in ACP. The scale has been validated in Chinese.
Older adults' and family caregivers' decisional conflict
Decisional conflict will be measured by both older adults' and family caregivers' responses to the Decisional Conflict Scale (DCS), which consists of 16 items in 5 domains (informed, values clarity, support, uncertainty, and effective decision) scored on a 5-point Likert scale, ranging from 1 (worst outcome) to 5 (best outcome). A Higher scores indicate more decisional conflict when considering goal of EOL care. The DCS has been validated in a Chinese population.
Older adults and family caregivers' congruence in goal of EOL care
Congruence in goal of EOL care will be assessed by the dyad's response to a scenario case (DSC-2) separately "in the event that I (the older adult participant) am in the terminal ill situation …." Each member of the dyad will independently choose one of three options: "the goals of care should be focused on prolonging my (his/her) life, no matter what it may cost," "b. the goals of care should be focused on my (his/her) comfort and peace, even though it may not extend life" or "I am not sure." The responses will be stratified and compared to assess the degree of congruence between older adults and family caregivers.
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