Post on 31-Mar-2020
For peer review only
Video Decision Aids to Assist with Advance Care Planning: a
Systematic Review and Meta-analysis
Journal: BMJ Open
Manuscript ID: bmjopen-2014-007491
Article Type: Research
Date Submitted by the Author: 18-Dec-2014
Complete List of Authors: Jain, Ashu; University of Toronto, Corriveau, Sophie; McMaster University, Quinn, Kathleen; McMaster University, Gardhouse, Amanda; University of Toronto, Brandt Vegas, Daniel; McMaster University, You, John; McMaster University, Medicine
<b>Primary Subject Heading</b>:
Patient-centred medicine
Secondary Subject Heading: Evidence based practice
Keywords: advance care planning, shared decision making, video, systematic review
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open on A
pril 8, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2014-007491 on 24 June 2015. Dow
nloaded from
For peer review only
December 18, 2014 1
Video Decision Aids to Assist with Advance Care Planning: a Systematic
Review and Meta-analysis
Ashu Jain, family medicine resident
Department of Family and Community Medicine, University of Toronto, 500 University
Avenue, 5th Floor, Toronto, Ontario, Canada M5G 1V7
Sophie Corriveau, respirology resident
Division of Respirology, Department of Medicine, McMaster University, St. Joseph’s
Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, Canada L8N 4A6
Kathleen Quinn, internal medicine resident
Department of Medicine, McMaster University, Room 3W10A-C, 1280 Main Street West,
Hamilton, Ontario, Canada L8S 4K1
Amanda Gardhouse, geriatric medicine resident
Division of Geriatric Medicine, Department of Medicine, University of Toronto, 2975
Bayview Avenue, Room H481, Toronto, Ontario, Canada, M4N 3M5
Daniel Brandt Vegas, clinical scholar
Division of General Internal Medicine, Department of Medicine, McMaster University, St.
Joseph’s Healthcare, Room F533, 50 Charlton Avenue East, Hamilton, Ontario, Canada L8N
4A6
Page 1 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 2
John J. You, associate professor (corresponding author)
Departments of Medicine, and Clinical Epidemiology & Biostatistics, McMaster University,
1280 Main Street West, Room HSC-2C8, Hamilton, Ontario, Canada, L8S 4K1; telephone:
905-525-9140 ext. 21858; e-mail: jyou@mcmaster.ca
Keywords: advance care planning; decision aids; video recording; cardiopulmonary
resuscitation; end of life care
Word count (excluding title page, abstract, acknowledgements, references, tables, figures):
3,115
Page 2 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 3
ABSTRACT
Objective: Advance care planning (ACP) can result in end-of-life care that is more
congruent with patients’ values and preferences. There is increasing interest in video
decision aids to assist with ACP. The objective of this study was to evaluate the impact of
video decision aids on patients’ preferences regarding life-sustaining treatments (primary
outcome).
Design: Systematic review and meta-analysis of randomized controlled trials.
Data sources: MEDLINE, EMBASE, PsycInfo, CINAHL, AMED, and CENTRAL, between 1980
and February 2014, and correspondence with authors.
Eligibility criteria for selecting studies: Randomized controlled trials of adult patients
that compared a video decision aid to a non-video based intervention to assist with choices
about use of life-sustaining treatments and reported at least one ACP-related outcome.
Data extraction: Reviewers worked independently and in duplicate to screen potentially
eligible articles, and to extract data regarding risk of bias, population, intervention,
comparator, and outcomes. Reviewers assessed quality of evidence (confidence in effect
estimates) for each outcome using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) framework.
Results: Ten trials enrolling 2,220 patients were included. Low quality evidence suggests
that patients who use a video decision aid are less likely to indicate a preference for
cardiopulmonary resuscitation (pooled risk ratio, 0.50 [95% CI, 0.27 to 0.95]; I2=65%).
Moderate quality evidence suggests that video decision aids result in greater knowledge
related to ACP (standardized mean difference, 0.58 [95% CI, 0.38 to 0.77]; I2=0%). No study
Page 3 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 4
reported on the congruence of end-of-life treatments with patients’ wishes. No study
evaluated the effect of video decision aids when integrated into clinical care.
Conclusions: Video decision aids may improve some ACP-related outcomes. More evidence
is needed to confirm these findings and to evaluate the impact of video decision aids when
integrated into patient care.
Page 4 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 5
ARTICLE SUMMARY
Strengths and limitations of this study
• This systematic review provides a synthesis of the available evidence from 10
randomized controlled trials about the impact of video decision aids to assist with
ACP.
• There is low to moderate quality evidence suggesting that video decision aids lead
to greater knowledge related to ACP, and preferences for less aggressive care at
end-of-life.
• To date, no studies have examined the effect of ACP video decision aids on
congruence of end-of-life treatment with patients’ preferences, nor have they
evaluated their impact when integrated into clinical care.
Page 5 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 6
INTRODUCTION
Individuals will often face important decisions about their care as they approach the
end of life, but many will lose capacity to make these decisions for themselves.1 Advance
care planning (ACP) offers a solution to this problem. ACP can be defined as a
communication and decision-making process which allows individuals to clarify their
values and preferences for future care and communicate their wishes to loved ones,
surrogate decision-makers, and healthcare providers.2 ACP may increase the likelihood
that patients’ wishes are known and respected at end of life, improve quality of life for
patients, and reduce caregiver regret during bereavement.3-5 Because of its potential
benefits, leading medical organizations have called for greater uptake of ACP to enhance
the quality of end-of-life care.6,7
Decision aids can increase patients’ knowledge of treatment options and outcomes,
help patients to clarify their own values, and increase patients’ participation in medical
decision making.8 As such, they may help increase the quality of ACP; however, a recent
overview of decision aids for ACP concluded that, while many decision aids are widely
available, there is need for greater evaluation of their effectiveness.9 Video decision aids for
ACP have garnered appreciable interest in the academic community, amongst health
policymakers, and in the popular press.10-12 Videos may assist with ACP because they can
dynamically depict diminishing health states and the nature of different treatment options,
and may help individuals to become more informed and confident about their preferences
for care at end of life. We conducted a systematic review to determine, amongst adult
patients, the impact of video decision aids on patients’ preferences for life sustaining
Page 6 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 7
treatments and other ACP-related outcomes, compared with non-video-based
interventions.
METHODS
Data Sources and Searches
A medical librarian searched MEDLINE, EMBASE, PsycInfo, CINAHL, the Allied and
Complementary Medicine Database (AMED), and the Cochrane Central Register of
Controlled Trials (CENTRAL) using terms such as “advanced care planning”, “video”, and
“end of life” for relevant articles published in any language between 1980 and February
2014 (see Web Appendix for detailed search strategy). The systematic review was not
registered with a central database.
Study Selection
Articles were eligible for inclusion if they reported original data from a randomized
controlled trial (RCT) which met each of the following criteria: (i) enrolled adult patients
(age 18 years or older) in an inpatient or outpatient setting; (ii) included an arm evaluating
an ACP video decision aid to assist with choices about future use of life-sustaining
treatments (e.g., cardiopulmonary resuscitation, intensive care unit admission); (iii)
included a comparator arm with no ACP video decision aid component (e.g. sham video,
traditional methods of decision support such as verbal description, pamphlets, usual care,
or no discussion); and (iv) reported data on at least one outcome of interest. The primary
outcome of interest for this review was patients’ preferences regarding the use of life-
sustaining treatments. We selected this primary outcome because patients are often
misinformed about the nature of life-sustaining treatments,13 such as CPR, and thus
Page 7 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 8
hypothesized that video decision aids aimed at assisting with choices about life-sustaining
treatments would have an effect on patients’ preferences.14 Secondary outcomes of interest
were: patients’ knowledge related to ACP (including knowledge about life sustaining
treatments), patients’ confidence in any decision made about future use of life-sustaining
treatments, completion of an advance directive, actual use of life-sustaining treatments at
end of life, whether the use of life-sustaining treatments at end of life was congruent with
patients’ prior expressed wishes, health resource use at end of life, and, for patients
allocated to the video intervention arm, patients’ comfort watching the video.
Using web-based systematic review software (DistillerSR™, Ottawa, Canada) paired
reviewers (A.J. and K.Q., A.G. and S.C.) independently conducted screening: first title and
abstracts, then full texts of articles in which either reviewer judged that titles or abstracts
appeared potentially eligible. Any disagreements between reviewers regarding final
eligibility at full-text review were resolved by discussion and additional consultation with a
third reviewer (J.J.Y.) when necessary.
Data Extraction and Quality Assessment
Two pairs of reviewers (A.J. and J.J.Y.; D.B.V. and J.J.Y.) assessed the methodological
quality of eligible studies and extracted data regarding the patient population,
interventions, comparators and outcomes using a standardized, pilot-tested data extraction
form developed by the investigators for this review. We assessed risk of bias using
Cochrane systematic review guidelines, which include an assessment of random sequence
generation, allocation concealment, blinding (of patients, healthcare providers, outcome
assessors, and analysts), and loss to follow-up.15 Any discrepancies during data extraction
Page 8 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 9
were resolved by discussion between reviewers. We contacted authors if we required
clarification of issues related to the conduct of the trial or missing data.
For each outcome of interest, we assessed the quality of evidence, defined as
confidence in the estimate of effect, using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) framework. In this approach, randomized controlled
trials begin as high quality evidence, but may be rated down due to limitations related to
risk of bias, indirectness, inconsistency (i.e., heterogeneity), imprecision and publication
bias.16
Data Synthesis and Analysis
For each outcome of interest, when possible, data were pooled to obtain a summary
estimate of effect. When data for a given outcome measure were collected at more than one
follow-up time point, we used data from the longest available follow-up time. When
outcome data were missing, we used a complete case analysis (i.e., subjects with missing
outcome data were excluded from the analysis if these data could not be obtained from
authors). For the primary outcome of patients’ preferences for use of life-sustaining
treatments, 4 studies elicited preferences in a dichotomous fashion (CPR versus no CPR),17-
20 and 3 studies elicited preferences using 3 response options: life prolonging care
(includes CPR), limited care (does not include CPR), or comfort care (does not include
CPR)21-23. In our pooled analyses, we treated patient preferences from the latter 3 studies
as a dichotomous outcome: CPR (life prolonging care), or no CPR (limited care or comfort
care).
For dichotomous outcome data, we used random effects models to calculate a
pooled risk ratio and 95% confidence interval, using the Mantel-Haenszel method. For
Page 9 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 10
continuous outcome data, we used random effects models to calculate a pooled
standardized mean difference and 95% confidence interval, using the inverse variance
method. Heterogeneity was assessed using a chi-squared test for heterogeneity and the I2
statistic. When there was evidence of substantial heterogeneity, defined as I2 statistic of
50% or greater, we conducted post-hoc sensitivity analyses to explore potential
explanations for heterogeneity. Analyses were performed using Review Manager (RevMan)
version 5.2 (Cophenhagen, The Nordic Cochrane Centre: The Cochrane Collaboration,
2012). We considered a P value of 0.05 to be statistically significant.
RESULTS
Of 3,980 citations identified from primary electronic databases, 583 were
duplicates, leaving 3,397 original publications. Of these, 125 underwent full-text screening,
and 10 RCTs were eligible for our review (Figure 1).17-26 Six of the studies were conducted
by the same group of investigators and published within the past 5 years.18-23 The other 4
studies were published in the late 1990s by 4 different research groups.17;24-26 Of the 6
authors we contacted, we received additional information from 4 (67%).
The 10 eligible RCTs enrolled a total of 2,220 patients, 1,092 of whom were
allocated to the video arm and 1,128 of whom were allocated to the control arm. Patients
were most often recruited from outpatient primary care or oncology settings (all in the
United States of America) and had a mean age between 51 and 81 years old (Table 1).
Videos used in the different studies were between 2 and 15 minutes in length, with some
videos focusing on the creation of advance directives,17;24-26 some including a visual
description of advanced dementia,22;23 some focusing on the delineation of 3 options for
Page 10 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 11
medical care (life prolonging care, limited medical care, and comfort care)18;21;23, and some
focusing on a description of CPR and the likelihood of its success in patients with advanced
cancer19;20 (Table 1). In 2 of the 10 trials, study procedures included a step which provided
an opportunity for patients to engage in some form of discussion with a healthcare
professional (their own physician,17 or a study nurse26) after they were exposed to the
study intervention (video or control). No study evaluated the impact of a video decision aid
when integrated into clinical workflow.
Risk of bias for the 10 included trials is summarized in Figure 2. Two studies
adequately concealed allocation.20;26 The remaining 8 studies either: did not conceal
allocation (n=1);17 used envelopes, but without procedures in place to enforce or audit
adherence to the allocation sequence (n=5);18;19;21-23 or did not report whether allocation
was concealed (n=2).24;25 In 6 of the studies,17;18;21-23;25 outcome assessors were not
blinded. Duration of follow-up was variable across the eligible studies. Seven studies
reported data on participants’ preferences for use of life sustaining treatments immediately
after receiving the study intervention,17-23 whereas some studies also elicited preferences
after 2 to 4 weeks follow-up (1 study),17 or 6 to 8 weeks follow-up (2 studies)19;22.
Completion of advance directive completion was assessed at 2 to 4 weeks in one study,17 at
3 months in 2 studies,25;26 and at 6 months in another study.20 Loss to follow-up was low
(0% to 11%) in 7 of the 10 included studies, whereas the studies by Siegert et al,24 Yamada
et al,17 Volandes et al,19 had higher rates of 14%, 23%, and 55% loss to follow-up,
respectively.
Page 11 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 12
Table 1. Characteristics of included studies
Study Population Video group Control group Video Control
Participants,
n
Mean age Participants,
n
Mean age
Epstein
201320
Patients with
progressive
pancreatic or
hepatobiliary
cancer from
outpatient
oncology clinics
in New York City
30 65 y 26 66 y 3 minute video
providing a narrative
description of CPR,
and likelihood of its
success in patients
with advanced cancer.
Images include
simulated CPR,
endotracheal
intubation, and a
sedated patient being
mechanically
ventilated in an ICU.
Verbal description of
CPR by research staff
(same script as video
arm).
Volandes
201319
Patients with
advanced cancer
from outpatient
clinics at 4
oncology centers
in Boston, New
York City, and
Nashville
70 63 y 80 62 y Verbal description by
research staff of CPR,
and likelihood of its
success in patients
with advanced cancer,
followed by a 3 minute
video. The video
repeats the same
narrative description
of CPR and included
images of simulated
CPR and endotracheal
intubation, and a
ventilated patient
receiving intravenous
medicines.
Verbal description of
CPR by research staff
(same script as video
arm).
Page 12 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
December 18, 2014 13
Volandes
201221
2 skilled nursing
facilities in
Boston
50 79 y 51 76 y 6 minute video
describing and
depicting 3 options for
care (life-prolonging
care, limited medical
care, comfort care).
Verbal description of
the same 3 options for
care as the video.
Volandes
201123
Primary care
clinic in rural
Louisiana
33 73 y 43 75 y Verbal description of
advanced dementia
and 3 options for care
(life-prolonging care,
limited medical care,
comfort care),
followed by a 6 minute
video. The video
describes and depicts
features of advanced
dementia and the 3
options for care.
Verbal description of
advanced dementia
and 3 options for care
(same script as video
arm).
El-Jawahri
201018
Patients with
malignant glioma
from outpatient
oncology clinics
in Boston
23 56 y 27 51 y Verbal description of 3
options for care (life-
prolonging care,
limited medical care,
comfort care),
followed by 6 minute
video. The video
describes and depicts
3 options for care.
Verbal description of 3
options for care (same
script as video arm).
Volandes
200922
Four primary
care clinics
affiliated with
teaching
hospitals in
Boston
94 75 y 106 75 y Verbal description of
principal features of
advanced dementia,
followed by 2 minute
video. The video
depicts the principal
features of advanced
dementia.
Verbal description of
principal features of
advanced dementia
(same script as video
arm).
Page 13 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
December 18, 2014 14
Brown
199926
Primary care
clinic in Colorado
619 81 y 628 81 y Mailed package
including a videotape
(Peace of Mind:
Advance Directives), of
9 patient or family
member interviews,
plus the same printed
materials as control.
Mailed package of
printed materials
including an
educational pamphlet
(You and Your
Choices), a Colorado
Advance Directive
Guide, and forms for
execution of a durable
power of attorney for
health care, a living
will, and a CPR
directive.
Yamada
199917
General internal
medicine clinic of
a Veterans Affairs
Medical Center in
Michigan
62 74 y 55 74 y 10 minute video about
advance directives
(Advance Directives:
Guaranteeing Your
Health Care Rights), a
handout about CPR
and its outcomes, plus
the same handout as
control.
Handout describing
advance directives
only (i.e., not CPR).
Landry
199725
General internal
medicine clinic of
a military
teaching hospital
in Maryland
95 61 y 92 63 y 15 minute video
detailing advance
directives. The video
was part of a 60
minute seminar which
also included a
didactic presentation
about advance
directives, interactive
question and answer
session, and review of
a recommended
advance directive
form.
Mailed advance
directive form and
information pamphlet.
Page 14 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
December 18, 2014 15
Siegert
199624
Nursing home
care unit of a
Veterans Affairs
Medical Center in
North Carolina
16 69 y 20 69 y 14 minute video (The
Right to Die … The
Choice is Yours) about
advance directives.
25 minute sham video
(I Am Joe’s Heart)
about heart disease
prevention strategies.
CPR, cardiopulmonary resuscitation; ICU, intensive care unit
Page 15 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
December 18, 2014 16
Patient preferences for use of life-sustaining treatments
Seven studies reported on patient preferences for use of life-sustaining
treatments.17-23 Low quality evidence (rated down for risk of bias and inconsistency)
suggests that, after receiving the video intervention, patients were less likely to indicate a
preference for CPR compared to those in the control arm (risk ratio, 0.50 [95% CI, 0.27 to
0.95]; I2 = 65%; heterogeneity P = 0.01) (Figure 3). The substantial heterogeneity across
studies appears to be driven by the study by Yamada et al,17 which was published over a
decade earlier than the 6 other RCTs which reported on this outcome, and had a much
higher proportion of patients indicating a preference for CPR than the other studies. In a
post hoc sensitivity analysis which excluded this study, patients allocated to the video arm
were again less likely to indicate a preference for CPR compared to those in the control arm
and there was no significant heterogeneity (risk ratio, 0.42 [95% CI, 0.26 to 0.67]; I2 = 0%;
heterogeneity P = 0.44).
Knowledge related to advance care planning
One study found that a video decision aid increased the proportion of patients with
correct responses to questions about the interventions included with CPR (intravenous
fluid, endotracheal intubation, mechanical ventilation, defibrillation), the likely outcomes of
CPR, and about advance directives; however, with the exception of increased knowledge
about advance directives, other estimates of effect were imprecise and not statistically
significant.17
Five studies reported on knowledge related to different aspects of ACP using a
variety of measurement scales.18-20;22;24 One study assessed knowledge about living wills
and cardiopulmonary resuscitation,24 another study assessed knowledge about advanced
Page 16 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 17
dementia,22 and 3 studies assessed knowledge about CPR.18-20 One of the latter studies
(Epstein et al.) did not report sufficient detail to allow inclusion in our pooled analysis; this
study found no significant difference in knowledge between the intervention and control
arms.20 In the 4 studies with poolable data, there was moderate quality evidence (rated
down for risk of bias) that video decision aids resulted in greater knowledge scores
compared to control (standardized mean difference, 0.58 [95% CI, 0.39 to 0.77]; I2 = 0%;
heterogeneity P = 0.99) (Figure 4).
Completion of advance directives
Four trials reported data on completion of advance directives.17;20;25;26 Low quality
evidence (rated down for risk of bias and imprecision) suggests there may be a small effect
of video decision aids on this outcome, but with a wide 95% confidence interval including
no effect (risk ratio, 1.11 [95% CI, 0.85 to 1.46]; I2 = 44%; heterogeneity P = 0.15) (Figure
5).
Other outcomes
El-Jawahri and colleagues found that a video decision aid led to greater confidence
in patients’ decisions about future use of life sustaining treatments compared to control, as
measured using the uncertainty subscale of the Decisional Conflict Scale (0=complete
uncertainty, 15=perfect certainty)27 (mean scores 13.7 in video group vs. 11.5 in control
group, p=0.002). In 5 of the studies, patients in the video arm were asked to rate their
comfort with watching the video.18-22 The majority of patients indicated that they were very
comfortable (83%18, 69%20), or at least somewhat comfortable (85%22, 90%21, 93%19)
watching the video.
Page 17 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 18
One study included in this review, a pilot RCT, reported data on use of life-
sustaining treatments and resource use at the end-of-life, and found that a video decision-
aid was not associated with a statistically significant difference in hospital admissions at 6
month follow-up (or until time of death), or hospital length of stay.20 However, this study
may not have been adequately powered to show a difference in these outcomes and does
not exclude the possibility of an effect. In this study, there were no intensive care unit
admissions during 6 month follow-up for the 30 subjects randomized to the video arm, and
3 intensive care unit admissions in the 26 subjects randomized to control; during 6 month
follow-up there was 1 episode of CPR or mechanical ventilation in the video arm and 3
episodes of CPR or mechanical ventilation in the control arm. No studies reported whether
the use of video decision aids affected the congruence of life-sustaining treatments at end-
of-life with patients’ prior expressed wishes.
DISCUSSION
In this systematic review of randomized controlled trials, we found low to moderate
quality evidence suggesting that video decision aids lead to greater knowledge related to
ACP and preferences for less aggressive care at end-of-life. Studies of ACP video decision
aids to date provide little or no data on other important outcomes related to ACP, such as
confidence in decision-making, the actual use of life sustaining treatments at end-of-life, or
the congruence of end-of-life treatments with patients’ wishes.
Strengths of our review include adherence to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) standards for conduct and reporting of a
systematic review, including a comprehensive literature search and a systematic approach
Page 18 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 19
for categorizing confidence in the effect estimates (GRADE).15;16;28 There are limitations
regarding the studies included in our review. First, there are differences across the eligible
RCTs. Studies clustered into a group of more recent studies conducted by the same group of
investigators (Volandes et al) and a group of studies published in the 1990s. Our intention
for this systematic review was to be comprehensive and inclusive of the entire body of
RCTs regarding video decision aids for ACP, but we acknowledge that the older studies may
have differed from more recent ones in several important ways. For instance, the focus of
the video interventions in the 1990s was on the creation of advance directives, whereas
more recent video interventions have focused on clarifying preferences for goals of care
(life prolonging care, limited care, or comfort care) or CPR. Eligible studies also elicited
preferences in different ways and it is possible that framing of response options as a binary
choice (CPR versus no CPR) or as choice between 3 options (life prolonging care, limited
care, or comfort care) may have influenced participants’ stated preferences. Another
limitation of the existing studies is that they report little or no data on other outcomes
relevant to ACP, such as confidence in decision-making, resource use at end-of-life, and
congruence of end-of-life care with patient wishes.
Butler et al recently completed a technical brief, commissioned by the Agency for
Healthcare Research and Quality in the United States, to provide an overview of a broad
range of ACP decision aids for adults.9 The report provides a state-of-the art review of the
field but, because it used technical brief methodology, it did not include a synthesis or
meta-analysis of outcomes, ratings of risk of bias or assessment of the quality of evidence.
It also did not include several randomized controlled trials of video decision aids for ACP
that were identified in our review, including several recent trials.18-21 Our review provides
Page 19 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 20
complementary and contemporary data on a well-specified clinical question (Amongst
adult patients, do video decision aids have an effect on outcomes related to ACP, when
compared to non-video-based interventions?), including assessments of risk of bias, quality
of evidence, and a synthesis of outcomes.
We found a large and statistically significant effect of video decision aids on patients’
preferences for CPR, with those exposed to the video intervention being half as likely to
prefer CPR as those exposed to a non-video based intervention. It is possible that some of
this effect is a result of bias introduced by incomplete concealment of allocation or
unblinded outcome assessment, as opposed to a true effect of the video decision aid. It is
also possible that some of the observed effect is attributable to the “dose” of information
received in the intervention arms: 4 of the 7 studies which reported on patients’
preferences presented the same information twice in the intervention arm (once as a
verbal description and once in video format) compared to once in the control arm (verbal
description only). Finally, it is possible that there is a true effect of video decision aids on
patients’ preferences for CPR.
It is notable that only 1 of the 10 studies (by Yamada et al) included a process
through which patients could engage in deliberation or discussion with their usual
healthcare provider after watching the video; despite this, few participants in this study
(12%) reported discussing the content of the video with their physician.17 Most notably,
none of the studies in our review evaluated the impact of a video decision aid when
integrated into clinical care. To have a measurable impact on downstream outcomes
related to ACP, such as resource use at end of life and congruence of end-of-life care with
patient wishes, we posit that video decision aids need to be embedded in a larger shared
Page 20 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 21
decision-making process which includes not only information exchange (the focus of the
video-based interventions to date) but also engages patients in a process of deliberation
with their healthcare provider and surrogate decision maker, and documentation of any
decisions made in the medical record.29
In conclusion, there is low to moderate quality evidence suggesting that video
decision aids may result in greater knowledge related to ACP and preferences for less
aggressive care at end of life. It remains unknown whether these tools can increase
congruence of end-of-life care with patient wishes. While video decision aids appear to be
promising tools to assist with ACP, further evaluation, especially when integrated into
clinical care, is needed before their widespread adoption into practice.
ACKNOWLEDGEMENTS
The authors thank Ms. Neera Bhatnagar for her assistance in the design and conduct
of the literature search for this systematic review, and Drs. Gordon Guyatt and Jason Busse
for their methodological advice. Dr. John You is supported by a Research Early Career
Award from Hamilton Health Sciences.
Contributors: AJ and JJY conceived of and designed the study. JJY is guarantor. AJ, KQ, SC,
and AG screened titles, abstracts, and full-text articles for eligibility. AJ, DBV and JJY
extracted data from eligible articles. SC and JJY analyzed the data. All authors participated
in: interpretation of data, drafting of the manuscript, and gave final approval of the version
to be published. All authors had full access to all of the data in the study and can take
responsibility for the integrity of the data and the accuracy of the data analysis.
Page 21 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 22
Competing interests: All authors have completed the Unified Competing Interest form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
All authors declare that: they have no relationships with companies that might have an
interest in the submitted work in the previous 3 years; their spouses, partners, or children
have no financial relationships that may be relevant to the submitted work; and they have
no non-financial interests that may be relevant to the submitted work.
Ethics approval: Ethics approval was not required for this study.
Funding: This research received no specific grant from any funding agency in the public,
commercial or not-for-profit sectors.
Transparency declaration: JJY (the manuscript's guarantor) affirms that the manuscript
is an honest, accurate, and transparent account of the study being reported; that no
important aspects of the study have been omitted; and that any discrepancies from the
study as planned have been explained.
Data sharing: The study dataset is available from the corresponding author at
jyou@mcmaster.ca.
Page 22 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 23
REFERENCES
(1) Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate
decision making before death. N Engl J Med 2010;362:1211-1218.
(2) Sudore RL, Fried TR. Redefining the "planning" in advance care planning:
preparing for end-of-life decision making. Ann Intern Med 2010;153:256-261.
(3) Detering KM, Hancock AD, Reade MC, et al. The impact of advance care planning on
end of life care in elderly patients: randomised controlled trial. BMJ
2010;340:c1345.
(4) Wright AA, Zhang B, Ray A et al. Associations between end-of-life discussions,
patient mental health, medical care near death, and caregiver bereavement
adjustment. JAMA 2008;300:1665-1673.
(5) Mullick A, Martin J, Sallnow L. An introduction to advance care planning in
practice. BMJ 2013;347:f6064.
(6) Cook D, Rocker G, Heyland D. Enhancing the quality of end-of-life care in Canada.
CMAJ 2013;185:1383-1384.
(7) IOM (Institute of Medicine). Dying in America: Improving quality and honoring
individual preferences near the end of life. Washington, DC: The National
Academies Press; 2014.
(8) Stacey D, Legare F, Col NF et al. Decision aids for people facing health treatment or
screening decisions. Cochrane Database Syst Rev 2014;1:CD001431.
(9) Butler M, Ratner E, McCreedy E, et al. Decision aids for advance care planning: an
overview of the state of the science. Ann Intern Med 2014;161:408-418.
(10) Hostetter M, Klein S. Helping Patients Make Better Treatment Choices with
Decision Aids. Quality Matters. Available from: The Commonwealth Fund. Accessed
at http://www.commonwealthfund.org/Newsletters/Quality-
Matters/2012/October-November/In-Focus.aspx on February 4, 2014.
(11) Volandes AE, Barry MJ, Chang Y, et al. Improving decision making at the end of life
with video images. Med Decis Making 2010;30:29-34.
(12) Sun LH. Videos aim to inform patients about their medical options at the end of
life. The Washington Post. Accessed at
http://www.washingtonpost.com/national/health-science/videos-aim-to-inform-
patients-about-their-medical-options-at-the-end-of-life/2014/06/02/b0eae002-
c63f-11e3-8b9a-8e0977a24aeb_story.html on June 2, 2014.
Page 23 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 24
(13) Heyland DK, Frank C, Groll D et al. Understanding cardiopulmonary resuscitation
decision making: perspectives of seriously ill hospitalized patients and family
members. Chest 2006;130:419-428.
(14) Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival
on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med
1994;330:545-549.
(15) Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. www cochrane-handbook org [serial online] 2011;
Available from: The Cochrane Collaboration.
(16) Guyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence" and why is it
important to clinicians? BMJ 2008;336:995-998.
(17) Yamada R, Galecki AT, Goold SD, et al. A multimedia intervention on
cardiopulmonary resuscitation and advance directives. J Gen Intern Med
1999;14:559-563.
(18) El-Jawahri A, Podgurski LM, Eichler AF, et al. Use of video to facilitate end-of-life
discussions with patients with cancer: a randomized controlled trial. J Clin Oncol
2010;28:305-310.
(19) Volandes AE, Paasche-Orlow MK, Mitchell SL, et al. Randomized controlled trial of
a video decision support tool for cardiopulmonary resuscitation decision making
in advanced cancer. J Clin Oncol 2013;31:380-386.
(20) Epstein AS, Volandes AE, Chen LY, et al. A randomized controlled trial of a
cardiopulmonary resuscitation video in advance care planning for progressive
pancreas and hepatobiliary cancer patients. J Palliat Med 2013;16:623-631.
(21) Volandes AE, Brandeis GH, Davis AD, et al. A randomized controlled trial of a goals-
of-care video for elderly patients admitted to skilled nursing facilities. J Palliat Med
2012;15:805-811.
(22) Volandes AE, Paasche-Orlow MK, Barry MJ, et al. Video decision support tool for
advance care planning in dementia: randomised controlled trial. BMJ
2009;338:b2159.
(23) Volandes AE, Ferguson LA, Davis AD, et al. Assessing End-of-Life Preferences for
Advanced Dementia in Rural Patients Using an Educational Video: A Randomized
Controlled Trial. J Palliat Med 2011;14:169-177.
(24) Siegert EA, Clipp EC, Mulhausen P, et al. Impact of advance directive videotape on
patient comprehension and treatment preferences. Arch Fam Med 1996;5:207-
212.
Page 24 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
December 18, 2014 25
(25) Landry FJ, Kroenke K, Lucas C, et al. Increasing the use of advance directives in
medical outpatients. J Gen Intern Med 1997;12:412-415.
(26) Brown JB, Beck A, Boles M, et al. Practical methods to increase use of advance
medical directives. J Gen Intern Med 1999;14:21-26.
(27) O'Connor AM. Validation of a decisional conflict scale. Med Decis Making
1995;15:25-30.
(28) Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264-
9.
(29) Heyland DK, Tranmer J, Feldman-Stewart D. End-of-life decision making in the
seriously ill hospitalized patient: an organizing framework and results of a
preliminary study. J Palliat Care 2000;16 Suppl:S31-S39.
Page 25 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure1.Summaryofarticleselection
Potentially relevant articles from primary
databases (n = 3980)
Articles evaluated at title and abstract
screening (n = 3397)
Duplicates (n = 583)
Excluded (n = 3272) Reasons: not on video
decision aids, not an RCT, not about ACP
Articles evaluated at full‐text screening
(n = 125) Excluded (n = 115)
Reasons: not on video decision aids, no control arm data, does not report on an outcome of interest, not an
RCTEligible RCTs included in
review (n = 10)
Page 26 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 2. Risk of bias in eligible studies
Legend
Low risk of bias
High risk of bias
Unclear risk of bias
Page 27 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Page 28 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 4. Effect of video decision aids on knowledge related to advance care planning
Page 29 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 5. Effect of video decision aids on completion of advance directives
Page 30 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
1
Web Appendix 1. Detailed description of literature search strategy
The following search strategy was used for Medline and was adapted for CENTRAL, EMBASE,
PsycInfo, AMED and CINAHL.
Database: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R)
<1980 to Present>
--------------------------------------------------------------------------------
1. Videotape Recording/
2. video*.mp.
3. (VHS or DVD* or blue-ray disc* or Compact Disc* or CDs or audiovisual).mp.
4. ((interactive or digital) adj5 media).mp.
5. or/1-4
6. exp advance care planning/ or life support care/ or palliative care/ or exp terminal care/ or
advance directives/ or living will/
7. (Advance Care Planning or ACP or care at the end of life initiative or CEOL or Goals of care
or GCD or end of life or living will*).mp.
8. or/6-7
9. exp Resuscitation/
10. Resuscitat*.mp.
11. CPR.mp.
12. exp Respiration, Artificial/
13. (Ventilator* or Ventilation*).mp.
14. exp Ventilators, Negative-Pressure/
15. (bilevel positive airway pressure or BiPAP or BPAP).mp.
16. (positive pressure* or positivepressure*).mp.
17. (Respiratory or Respiration*).mp.
18. exp Intubation/
19. Airway Management/
20. (intubate* or intubation).mp.
21. Esophageal.mp.
22. (Laryngeal mask or LMA).mp.
23. (Tracheostom* or Tracheotom*).mp.
24. Enteral Nutrition/
25. ((enter* or nasogastric or NG) adj5 (feed* or nutrition* or immunonutrition*)).mp.
26. nasoduodenal tube*.mp.
27. Feeding Methods/
28. exp Parenteral Nutrition/
29. ((Parenteral* or intravenous) adj3 (feeding* or nutrition)).mp.
30. (TPN or PN).mp.
31. ((Nasogastric or NG or gastrostomy or jejunostomy or gastric or orogastric or nasoenteric
or nasojejunal or nasointestinal or transabdominal) adj3 (intubat* or tube* or feed*)).mp.
32. ((artificial or force or tube) adj3 (feeding* or nutrition)).mp.
33. tube feeding/
Page 31 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
2
34. (Percutaneous endoscopic gastrostomy or PPEG).mp.
35. ((RIG or PEG) and (Percutaneous or endoscopic or gastrostomy)).mp.
36. exp Renal Replacement Therapy/
37. Kidney, Artificial/ or artificial kidney*.mp.
38. (dialyzer or hemodialysis or dialysis).mp.
39. Critical Care/
40. Critical Illness/
41. exp Intensive Care Units/
42. ICU*.mp.
43. ((critical or intensive) adj3 (care or illness)).tw.
44. (ACLS or Advanced cardiovascular life support).mp.
45. Defibrillation.mp.
46. or/9-45
47. exp Patient Satisfaction/ or patient centered care/ or exp choice behavior/ or attitude to
health/ or attitude to death/ or personal autonomy/ or patient participation/ or patient
education as topic/
48. ((patient* or Individual* or caregiver* or care-giver*) adj10 (wish* or value* or desire* or
desirability or selection or prefer* or decide* or decision* or choice* or chose* or want* or
participat*)).mp.
49. exp Decision Making/ or Decision Support Techniques/ or decision aid*.mp.
50. exp Patients/ or patient*.mp. or caregivers/ or caregiver*.mp. or care-giver*.mp.
51. 49 and 50
52. 47 or 48 or 51
53. 5 and 8
54. 5 and 46 and 52
55. 53 or 54
***************************
Life-sustaining treatments of interest:
1. Cardiopulmonary resuscitation (CPR)
2. Mechanical ventilation
3. Respirator
4. Ventilator
5. Endotracheal intubation
6. Enteral feeding
7. Enteral nutrition
8. Total parenteral nutrition
9. Nasogastric tube feeding
10. Tube feeding
11. Percutaneous endoscopic gastrostomy (PEG) tube
12. Hemodialysis
13. Dialysis
14. Intensive care unit
Page 32 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
3
15. Critical care unit
16. Advanced cardiac life support (=ACLS)
17. Advanced cardiovascular life support (=ACLS)
18. Defibrillation
19. Cardiac defibrillation
Page 33 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Section/topic # Checklist item Reported on page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 1
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.
3-4
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 6
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
6-7
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
7
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale. 7-8
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
7
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
Web Appendix
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).
8-9
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
8-9
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
7-9
Risk of bias in individual studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
8
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 9-10
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency
(e.g., I2) for each meta-analysis.
9-10
Page 34 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Page 1 of 2
Section/topic # Checklist item Reported on page #
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
--
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.
16
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
Fig 1
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Table 1
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). p.11; Figure 2
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
p. 16-18; Figs 3-5
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. p. 16-18; Figs 3-5
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). --
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). 16
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
18-21
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
19
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 18-21
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.
22
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma-statement.org.
Page 35 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Page 2 of 2
Page 36 of 36
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
Video Decision Aids to Assist with Advance Care Planning: a
Systematic Review and Meta-analysis
Journal: BMJ Open
Manuscript ID: bmjopen-2014-007491.R1
Article Type: Research
Date Submitted by the Author: 03-May-2015
Complete List of Authors: Jain, Ashu; University of Toronto, Corriveau, Sophie; McMaster University, Quinn, Kathleen; McMaster University, Gardhouse, Amanda; University of Toronto, Brandt Vegas, Daniel; McMaster University, You, John; McMaster University, Medicine
<b>Primary Subject Heading</b>:
Patient-centred medicine
Secondary Subject Heading: Evidence based practice
Keywords: advance care planning, shared decision making, video, systematic review
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open on A
pril 8, 2020 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2014-007491 on 24 June 2015. Dow
nloaded from
For peer review only
May 3, 2015 1
Video Decision Aids to Assist with Advance Care Planning: a Systematic
Review and Meta-analysis
Ashu Jain, family medicine resident
Department of Family and Community Medicine, University of Toronto, 500 University
Avenue, 5th Floor, Toronto, Ontario, Canada M5G 1V7
Sophie Corriveau, respirology resident
Division of Respirology, Department of Medicine, McMaster University, St. Joseph’s
Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, Canada L8N 4A6
Kathleen Quinn, internal medicine resident
Department of Medicine, McMaster University, Room 3W10A-C, 1280 Main Street West,
Hamilton, Ontario, Canada L8S 4K1
Amanda Gardhouse, geriatric medicine resident
Division of Geriatric Medicine, Department of Medicine, University of Toronto, 2975
Bayview Avenue, Room H481, Toronto, Ontario, Canada, M4N 3M5
Daniel Brandt Vegas, clinical scholar
Division of General Internal Medicine, Department of Medicine, McMaster University, St.
Joseph’s Healthcare, Room F533, 50 Charlton Avenue East, Hamilton, Ontario, Canada L8N
4A6
Page 1 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 2
John J. You, associate professor (corresponding author)
Departments of Medicine, and Clinical Epidemiology & Biostatistics, McMaster University,
1280 Main Street West, Room HSC-2C8, Hamilton, Ontario, Canada, L8S 4K1; telephone:
905-525-9140 ext. 21858; e-mail: jyou@mcmaster.ca
Keywords: advance care planning; decision aids; video recording; cardiopulmonary
resuscitation; end of life care
Word count (excluding title page, abstract, acknowledgements, references, tables, figures):
3,525
Page 2 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 3
ABSTRACT
Objective: Advance care planning (ACP) can result in end-of-life care that is more
congruent with patients’ values and preferences. There is increasing interest in video
decision aids to assist with ACP. The objective of this study was to evaluate the impact of
video decision aids on patients’ preferences regarding life-sustaining treatments (primary
outcome).
Design: Systematic review and meta-analysis of randomized controlled trials.
Data sources: MEDLINE, EMBASE, PsycInfo, CINAHL, AMED, and CENTRAL, between 1980
and February 2014, and correspondence with authors.
Eligibility criteria for selecting studies: Randomized controlled trials of adult patients
that compared a video decision aid to a non-video based intervention to assist with choices
about use of life-sustaining treatments and reported at least one ACP-related outcome.
Data extraction: Reviewers worked independently and in duplicate to screen potentially
eligible articles, and to extract data regarding risk of bias, population, intervention,
comparator, and outcomes. Reviewers assessed quality of evidence (confidence in effect
estimates) for each outcome using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) framework.
Results: Ten trials enrolling 2,220 patients were included. Low quality evidence suggests
that patients who use a video decision aid are less likely to indicate a preference for
cardiopulmonary resuscitation (pooled risk ratio, 0.50 [95% CI, 0.27 to 0.95]; I2=65%).
Moderate quality evidence suggests that video decision aids result in greater knowledge
related to ACP (standardized mean difference, 0.58 [95% CI, 0.38 to 0.77]; I2=0%). No study
Page 3 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 4
reported on the congruence of end-of-life treatments with patients’ wishes. No study
evaluated the effect of video decision aids when integrated into clinical care.
Conclusions: Video decision aids may improve some ACP-related outcomes. Before
recommending their use in clinical practice, more evidence is needed to confirm these
findings and to evaluate the impact of video decision aids when integrated into patient
care.
Page 4 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 5
ARTICLE SUMMARY
Strengths and limitations of this study
• This systematic review provides a synthesis of the available evidence from 10
randomized controlled trials about the impact of video decision aids to assist with
advance care planning (ACP).
• There is low to moderate quality evidence suggesting that video decision aids lead
to greater knowledge related to ACP, and preferences for less aggressive care at
end-of-life.
• To date, no studies have examined the effect of ACP video decision aids on
congruence of end-of-life treatment with patients’ preferences, nor have they
evaluated their impact when integrated into clinical care.
Page 5 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 6
INTRODUCTION
Individuals will often face important decisions about their care as they approach the
end of life, but many will lose capacity to make these decisions for themselves.1 Advance
care planning (ACP) offers a solution to this problem. ACP can be defined as a
communication and decision-making process which allows individuals to clarify their
values and preferences for future care and communicate their wishes to loved ones,
surrogate decision-makers, and healthcare providers.2 ACP may increase the likelihood
that patients’ wishes are known and respected at end of life, improve quality of life for
patients, and reduce caregiver regret during bereavement.3-5 Because of its potential
benefits, leading medical organizations have called for greater uptake of ACP to enhance
the quality of end-of-life care.6,7
Decision aids can increase patients’ knowledge of treatment options and outcomes,
help patients to clarify their own values, and increase patients’ participation in medical
decision making.8 As such, they may help increase the quality of ACP; however, a recent
overview of decision aids for ACP concluded that, while many decision aids are widely
available, there is need for greater evaluation of their effectiveness.9 Video decision aids for
ACP have garnered appreciable interest in the academic community, amongst health
policymakers, and in the popular press.10-12 Videos may assist with ACP because they can
dynamically depict diminishing health states and the nature of different treatment options,
and may help individuals to become more informed and confident about their preferences
for care at end of life. We conducted a systematic review to determine, amongst adult
patients, the impact of video decision aids on patients’ preferences for life sustaining
Page 6 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 7
treatments and other ACP-related outcomes, compared with non-video-based
interventions.
METHODS
Data Sources and Searches
A medical librarian searched MEDLINE, EMBASE, PsycInfo, CINAHL, the Allied and
Complementary Medicine Database (AMED), and the Cochrane Central Register of
Controlled Trials (CENTRAL) using terms such as “advance care planning”, “video”, and
“end of life” for relevant articles published in any language between 1980 and February
2014 (see Web Appendix for detailed search strategy). The systematic review was not
registered with a central database.
Study Selection
Articles were eligible for inclusion if they reported original data from a randomized
controlled trial (RCT) which met each of the following criteria: (i) enrolled adult patients
(age 18 years or older) in an inpatient or outpatient setting; (ii) included an arm evaluating
an ACP video decision aid to assist with choices about future use of life-sustaining
treatments (e.g., cardiopulmonary resuscitation, intensive care unit admission); (iii)
included a comparator arm with no ACP video decision aid component (e.g. sham video,
traditional methods of decision support such as verbal description, pamphlets, usual care,
or no discussion); and (iv) reported data on at least one outcome of interest. The primary
outcome of interest for this review was patients’ preferences regarding the use of life-
sustaining treatments. We selected this primary outcome because patients are often
misinformed about the nature of life-sustaining treatments,13 such as CPR, and thus
Page 7 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 8
hypothesized that video decision aids aimed at assisting with choices about life-sustaining
treatments would have an effect on patients’ preferences.14 Secondary outcomes of interest
were: patients’ knowledge related to ACP (including knowledge about life sustaining
treatments), patients’ confidence in any decision made about future use of life-sustaining
treatments, completion of an advance directive (as defined by the authors of the individual
studies), actual use of life-sustaining treatments at end of life, whether the use of life-
sustaining treatments at end of life was congruent with patients’ prior expressed wishes,
health resource use at end of life, and, for patients allocated to the video intervention arm,
patients’ comfort watching the video.
Using web-based systematic review software (DistillerSR™, Ottawa, Canada) paired
reviewers (A.J. and K.Q., A.G. and S.C.) independently conducted screening: first title and
abstracts, then full texts of articles for which either reviewer judged that titles or abstracts
appeared potentially eligible. Any disagreements between reviewers regarding final
eligibility at full-text review were resolved by discussion and additional consultation with a
third reviewer (J.J.Y.) when necessary.
Data Extraction and Quality Assessment
Two pairs of reviewers (A.J. and J.J.Y.; D.B.V. and J.J.Y.) assessed the methodological
quality of eligible studies and extracted data regarding the patient population,
interventions, comparators and outcomes using a standardized, pilot-tested data extraction
form developed by the investigators for this review. We assessed risk of bias using
Cochrane systematic review guidelines, which include an assessment of random sequence
generation, allocation concealment, blinding (of patients, healthcare providers, outcome
assessors, and analysts), and loss to follow-up.15 Any discrepancies during data extraction
Page 8 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 9
were resolved by discussion between reviewers. We contacted authors if we required
clarification of issues related to the conduct of the trial or missing data.
For each outcome of interest, we assessed the quality of evidence, defined as
confidence in the estimate of effect, using the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) framework. In this approach, randomized controlled
trials begin as high quality evidence, but may be rated down due to limitations related to
risk of bias, indirectness, inconsistency (i.e., heterogeneity), imprecision and publication
bias.16
Data Synthesis and Analysis
We used Cohen’s kappa to assess chance-corrected inter-rater agreement of
reviewers’ decisions about potential eligibility of articles at title and abstract screening,
and about the eligibility of articles at full-text review. For each outcome of interest, when
possible, data were pooled to obtain a summary estimate of effect. When data for a given
outcome measure were collected at more than one follow-up time point, we used data from
the longest available follow-up time. When outcome data were missing, we used a complete
case analysis (i.e., subjects with missing outcome data were excluded from the analysis if
these data could not be obtained from authors). For the primary outcome of patients’
preferences for use of life-sustaining treatments, 4 studies elicited preferences in a
dichotomous fashion (CPR versus no CPR),17-20 and 3 studies elicited preferences using 3
response options: life prolonging care (includes CPR), limited care (does not include CPR),
or comfort care (does not include CPR)21-23. In our pooled analyses, we treated patient
preferences from the latter 3 studies as a dichotomous outcome: CPR (life prolonging care),
or no CPR (limited care or comfort care).
Page 9 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 10
For dichotomous outcome data, we used random effects models (using the method
of DerSimonian and Laird) to calculate pooled risk ratios and 95% confidence intervals. For
continuous outcome data, we used random effects models to calculate a pooled
standardized mean difference and 95% confidence interval. Heterogeneity was assessed
using a chi-squared test for heterogeneity and the I2 statistic. Analyses were performed
using Review Manager (RevMan) version 5.2 (Cophenhagen, The Nordic Cochrane Centre:
The Cochrane Collaboration, 2012). We considered a P value of 0.05 to be statistically
significant.
RESULTS
Of 3,980 citations identified from primary electronic databases, 583 were
duplicates, leaving 3,397 original publications. Of these, 125 were deemed potentially
eligible (kappa 0.29) and underwent full-text screening. Of these 125 full-text articles, 10
RCTs were eligible for our review (kappa 0.48) (Figure 1).17-26 Six of the studies were
conducted by the same group of investigators and published within the past 5 years.18-23
The other 4 studies were published in the late 1990s by 4 different research groups.17;24-26
Of the 6 authors we contacted, we received additional information from 4 (67%).
The 10 eligible RCTs enrolled a total of 2,220 patients, 1,092 of whom were
allocated to the video arm and 1,128 of whom were allocated to the control arm. Patients
were most often recruited from outpatient primary care or oncology settings (all in the
United States of America) and had a mean age between 51 and 81 years old (Table 1).
Videos used in the different studies were between 2 and 15 minutes in length, with some
videos focusing on the creation of advance directives,17;24-26 some including a visual
Page 10 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 11
description of advanced dementia,22;23 some focusing on the delineation of 3 options for
medical care (life prolonging care, limited medical care, and comfort care)18;21;23, and some
focusing on a description of CPR and the likelihood of its success in patients with advanced
cancer19;20 (Table 1). In 2 of the 10 trials, study procedures included a step which provided
an opportunity for patients to engage in some form of discussion with a healthcare
professional (their own physician,17 or a study nurse26) after they were exposed to the
study intervention (video or control). No study evaluated the impact of a video decision aid
when integrated into clinical workflow.
Risk of bias for the 10 included trials is summarized in Figure 2. Two studies
adequately concealed allocation.20;26 The remaining 8 studies either: did not conceal
allocation (n=1);17 used envelopes, but without procedures in place to enforce or audit
adherence to the allocation sequence (n=5);18;19;21-23 or did not report whether allocation
was concealed (n=2).24;25 In 6 of the studies,17;18;21-23;25 outcome assessors were not
blinded. Duration of follow-up was variable across the eligible studies. Seven studies
reported data on participants’ preferences for use of life sustaining treatments immediately
after receiving the study intervention,17-23 whereas some studies also elicited preferences
after 2 to 4 weeks follow-up (1 study),17 or 6 to 8 weeks follow-up (2 studies)19;22.
Completion of advance directive completion was assessed at 2 to 4 weeks in one study,17 at
3 months in 2 studies,25;26 and at 6 months in another study.20 Loss to follow-up, i.e., the
percentage of participants with missing outcome data, was low (0% to 11%) in 7 of the 10
included studies, whereas the studies by Siegert et al,24 Yamada et al,17 Volandes et al,19 had
higher rates of 14%, 23%, and 55% loss to follow-up (missing outcome data), respectively.
Page 11 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 12
Table 1. Characteristics of included studies
Study Population Video group Control group Video Control
Participants,
n
Mean age Participants,
n
Mean age
Epstein
201320
Patients with
progressive
pancreatic or
hepatobiliary
cancer from
outpatient
oncology clinics
in New York City
30 65 y 26 66 y 3 minute video
providing a narrative
description of CPR,
and likelihood of its
success in patients
with advanced cancer.
Images include
simulated CPR,
endotracheal
intubation, and a
sedated patient being
mechanically
ventilated in an ICU.
Verbal description of
CPR by research staff
(same script as video
arm).
Volandes
201319
Patients with
advanced cancer
from outpatient
clinics at 4
oncology centers
in Boston, New
York City, and
Nashville
70 63 y 80 62 y Verbal description by
research staff of CPR,
and likelihood of its
success in patients
with advanced cancer,
followed by a 3 minute
video. The video
repeats the same
narrative description
of CPR and included
images of simulated
CPR and endotracheal
intubation, and a
ventilated patient
receiving intravenous
medicines.
Verbal description of
CPR by research staff
(same script as video
arm).
Page 12 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
May 3, 2015 13
Volandes
201221
2 skilled nursing
facilities in
Boston
50 79 y 51 76 y 6 minute video
describing and
depicting 3 options for
care (life-prolonging
care, limited medical
care, comfort care).
Verbal description of
the same 3 options for
care as the video.
Volandes
201123
Primary care
clinic in rural
Louisiana
33 73 y 43 75 y Verbal description of
advanced dementia
and 3 options for care
(life-prolonging care,
limited medical care,
comfort care),
followed by a 6 minute
video. The video
describes and depicts
features of advanced
dementia and the 3
options for care.
Verbal description of
advanced dementia
and 3 options for care
(same script as video
arm).
El-Jawahri
201018
Patients with
malignant glioma
from outpatient
oncology clinics
in Boston
23 56 y 27 51 y Verbal description of 3
options for care (life-
prolonging care,
limited medical care,
comfort care),
followed by 6 minute
video. The video
describes and depicts
3 options for care.
Verbal description of 3
options for care (same
script as video arm).
Volandes
200922
Four primary
care clinics
affiliated with
teaching
hospitals in
Boston
94 75 y 106 75 y Verbal description of
principal features of
advanced dementia,
followed by 2 minute
video. The video
depicts the principal
features of advanced
dementia.
Verbal description of
principal features of
advanced dementia
(same script as video
arm).
Page 13 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
May 3, 2015 14
Brown
199926
Primary care
clinic in Colorado
619 81 y 628 81 y Mailed package
including a videotape
(Peace of Mind:
Advance Directives), of
9 patient or family
member interviews,
plus the same printed
materials as control.
Mailed package of
printed materials
including an
educational pamphlet
(You and Your
Choices), a Colorado
Advance Directive
Guide, and forms for
execution of a durable
power of attorney for
health care, a living
will, and a CPR
directive.
Yamada
199917
General internal
medicine clinic of
a Veterans Affairs
Medical Center in
Michigan
62 74 y 55 74 y 10 minute video about
advance directives
(Advance Directives:
Guaranteeing Your
Health Care Rights), a
handout about CPR
and its outcomes, plus
the same handout as
control.
Handout describing
advance directives
only (i.e., not CPR).
Landry
199725
General internal
medicine clinic of
a military
teaching hospital
in Maryland
95 61 y 92 63 y 15 minute video
detailing advance
directives. The video
was part of a 60
minute seminar which
also included a
didactic presentation
about advance
directives, interactive
question and answer
session, and review of
a recommended
advance directive
form.
Mailed advance
directive form and
information pamphlet.
Page 14 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
May 3, 2015 15
Siegert
199624
Nursing home
care unit of a
Veterans Affairs
Medical Center in
North Carolina
16 69 y 20 69 y 14 minute video (The
Right to Die … The
Choice is Yours) about
advance directives.
25 minute sham video
(I Am Joe’s Heart)
about heart disease
prevention strategies.
CPR, cardiopulmonary resuscitation; ICU, intensive care unit
Page 15 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
May 3, 2015 16
Patient preferences for use of life-sustaining treatments
Seven studies reported on patient preferences for use of life-sustaining
treatments.17-23 Low quality evidence (rated down for risk of bias and inconsistency)
suggests that, after receiving the video intervention, patients were less likely to indicate a
preference for CPR compared to those in the control arm (risk ratio, 0.50 [95% CI, 0.27 to
0.95]; I2 = 65%; heterogeneity P = 0.01) (Figure 3). The substantial heterogeneity across
studies may have been driven by the study by Yamada et al,17 which was published over a
decade earlier than the 6 other RCTs which reported on this outcome, and had a much
higher proportion of patients indicating a preference for CPR than the other studies.
Knowledge related to advance care planning
One study found that a video decision aid increased the proportion of patients with
correct responses to questions about the interventions included with CPR (intravenous
fluid, endotracheal intubation, mechanical ventilation, defibrillation), the likely outcomes of
CPR, and about advance directives; however, with the exception of increased knowledge
about advance directives, other estimates of effect were imprecise and not statistically
significant.17
Five studies reported on knowledge related to different aspects of ACP using a
variety of measurement scales.18-20;22;24 One study assessed knowledge about living wills
and cardiopulmonary resuscitation,24 another study assessed knowledge about advanced
dementia,22 and 3 studies assessed knowledge about CPR.18-20 One of the latter studies
(Epstein et al.) did not report sufficient detail to allow inclusion in our pooled analysis.20 In
the 4 studies with poolable data,18;19;22;24 there was moderate quality evidence (rated down
for risk of bias) that video decision aids resulted in greater knowledge scores compared to
Page 16 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 17
control (standardized mean difference, 0.58 [95% CI, 0.39 to 0.77]; I2 = 0%; heterogeneity
P = 0.99) (Figure 4).
Completion of advance directives
Four trials reported data on completion of advance directives.17;20;25;26 One study
defined advance directives as “any document that instructed caregivers on details of future
care”,20 another study provided no definition,17 and two other studies reported data on the
completion of both living wills and durable powers of attorney for health care. For the
latter two studies, we used the data related to the completion of living wills.25,26 Low
quality evidence (rated down for risk of bias and imprecision) suggests there may be a
small effect of video decision aids on this outcome, but with a wide 95% confidence interval
including no effect (risk ratio, 1.11 [95% CI, 0.85 to 1.46]; I2 = 44%; heterogeneity P = 0.15)
(Figure 5).
Other outcomes
El-Jawahri and colleagues found that a video decision aid led to greater confidence
in patients’ decisions about future use of life sustaining treatments compared to control, as
measured using the uncertainty subscale of the Decisional Conflict Scale (0=complete
uncertainty, 15=perfect certainty)27 (mean scores 13.7 in video group vs. 11.5 in control
group, p=0.002). In 5 of the studies, patients in the video arm were asked to rate their
comfort with watching the video.18-22 The majority of patients indicated that they were very
comfortable (83%18, 69%20), or at least somewhat comfortable (85%22, 90%21, 93%19)
watching the video.
One study included in this review, a pilot RCT, reported data on use of life-
sustaining treatments and resource use at the end-of-life, and found that a video decision-
Page 17 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 18
aid was not associated with a statistically significant difference in hospital admissions at 6
month follow-up (or until time of death), or hospital length of stay.20 However, this study
may not have been adequately powered to show a difference in these outcomes and does
not exclude the possibility of an effect. In this study, there were no intensive care unit
admissions during 6 month follow-up for the 30 subjects randomized to the video arm, and
3 intensive care unit admissions in the 26 subjects randomized to control; during 6 month
follow-up there was 1 episode of CPR or mechanical ventilation in the video arm and 3
episodes of CPR or mechanical ventilation in the control arm. No studies reported whether
the use of video decision aids affected the congruence of life-sustaining treatments at end-
of-life with patients’ prior expressed wishes.
DISCUSSION
In this systematic review of randomized controlled trials, we found low to moderate
quality evidence suggesting that video decision aids lead to greater knowledge related to
ACP and preferences for less aggressive care at end-of-life. Studies of ACP video decision
aids to date provide little or no data on other important outcomes related to ACP, such as
confidence in decision-making, the actual use of life sustaining treatments at end-of-life, or
the congruence of end-of-life treatments with patients’ wishes. Although an important
aspect of ACP is to clarify patients’ preferences for life-sustaining treatments, including
CPR, ACP involves several other important processes. In contemporary thinking, the focus
of ACP is shifting away from making decisions about future treatment choices and putting
more emphasis on the need to prepare future surrogate decision makers for “in-the-
moment” decision-making.2 In this way, ACP can be seen as a broader set of behaviours,
Page 18 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 19
including: choosing a surrogate decision maker, deciding what matters most in life
(clarifying values and, in some cases, future wishes for treatments such as CPR), and
communicating these values and wishes to surrogate decision makers to better prepare
them to engage in future “in-the-moment” medical decision-making when the patient
becomes incapable. We did not find any RCTs of video decision aids that examined ACP
from this perspective. However, web-based decision aids have recently been designed to
change these different behaviours related to ACP.28-30
Strengths of our review include adherence to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) standards for conduct and reporting of a
systematic review, including a comprehensive literature search and a systematic approach
for categorizing confidence in the effect estimates (GRADE).15;16;31 Our systematic review
also has limitations. First, we restricted our search strategy to articles published in 1980 or
later and it is possible that we missed older, relevant articles. However, none of the trials
included in our review were published before 1996 and the concepts of advance directives
and advance care planning did not gain widespread attention until the 1990s (e.g., after the
introduction of the U.S. Patient Self-Determination Act in 1990). Second, for studies with
missing outcome data, we did not use imputation methods. By including only patients with
non-missing data (complete case analysis) in our meta-analyses, our resultant estimates of
effect could be biased if patients lost to follow-up were systematically different in ways that
were related to our outcomes of interest (e.g., if they were systematically more or less
likely to prefer CPR). Finally, our review also has limitations due to the limitations of the
studies included in our review. First, there are differences across the eligible RCTs. Studies
clustered into a group of more recent studies conducted by the same group of investigators
Page 19 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 20
(Volandes et al) and a group of studies published in the 1990s. Our intention for this
systematic review was to be comprehensive and inclusive of the entire body of RCTs
regarding video decision aids for ACP, but we acknowledge that the older studies may have
differed from more recent ones in several important ways. For instance, the focus of the
video interventions in the 1990s was on the creation of advance directives, whereas more
recent video interventions have focused on clarifying preferences for goals of care (life
prolonging care, limited care, or comfort care) or CPR. Eligible studies also elicited
preferences in different ways and it is possible that framing of response options as a binary
choice (CPR versus no CPR) or as choice between 3 options (life prolonging care, limited
care, or comfort care) may have influenced participants’ stated preferences. Another
limitation of the existing studies is that they report little or no data on other outcomes
relevant to ACP, such as confidence in decision-making, resource use at end-of-life, and
congruence of end-of-life care with patient wishes. This narrower focus of the existing
trials on the elicitation of treatment preferences or creation of advance directives, rather
than the broader range of activities that are part of ACP, and the fact that all the included
studies were done in the U.S. raise questions about the applicability of the available
evidence in other countries and in the context of changing definitions of ACP.
Butler et al recently completed a technical brief, commissioned by the Agency for
Healthcare Research and Quality in the United States, to provide an overview of a broad
range of ACP decision aids for adults.9 The report provides a state-of-the art review of the
field but, because it used technical brief methodology, it did not include a synthesis or
meta-analysis of outcomes, ratings of risk of bias or assessment of the quality of evidence.
It also did not include several randomized controlled trials of video decision aids for ACP
Page 20 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 21
that were identified in our review, including several recent trials.18-21 Our review provides
complementary and contemporary data on a well-specified clinical question (Amongst
adult patients, do video decision aids have an effect on outcomes related to ACP, when
compared to non-video-based interventions?), including assessments of risk of bias, quality
of evidence, and a synthesis of outcomes.
We found a large and statistically significant effect of video decision aids on patients’
preferences for CPR, with those exposed to the video intervention being half as likely to
prefer CPR as those exposed to a non-video based intervention. It is possible that some of
this effect is a result of bias introduced by incomplete concealment of allocation or
unblinded outcome assessment, as opposed to a true effect of the video decision aid. Future
trials could overcome these methodological limitations by using centralized telephone or
web-based randomization to preserve allocation concealment and blinding the outcome
assessors to allocation.32 It is also possible that some of the observed effect is attributable
to the “dose” of information received in the intervention arms: 4 of the 7 studies which
reported on patients’ preferences presented the same information twice in the intervention
arm (once as a verbal description and once in video format) compared to once in the
control arm (verbal description only). Finally, it is possible that there is a true effect of
video decision aids on patients’ preferences for CPR.
It is notable that only 1 of the 10 studies (by Yamada et al) included a process
through which patients could engage in deliberation or discussion with their usual
healthcare provider after watching the video; despite this, few participants in this study
(12%) reported discussing the content of the video with their physician.17 Most notably,
none of the studies in our review evaluated the impact of a video decision aid when
Page 21 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 22
integrated into clinical care. To have a measurable impact on downstream outcomes
related to ACP, such as resource use at end of life and congruence of end-of-life care with
patient wishes, we posit that video decision aids need to be embedded in a larger shared
decision-making process which includes not only information exchange (the focus of the
video-based interventions to date) but also engages patients in a process of deliberation
with their healthcare provider and surrogate decision maker, and documentation of any
decisions made in the medical record.33
In conclusion, there is low to moderate quality evidence suggesting that video
decision aids may result in greater knowledge related to ACP and preferences for less
aggressive care at end of life. It remains unknown whether these tools can increase
congruence of end-of-life care with patient wishes. While video decision aids appear to be
promising tools to assist with ACP, further evaluation, especially when integrated into
clinical care, is needed before their widespread adoption into practice.
ACKNOWLEDGEMENTS
The authors thank Ms. Neera Bhatnagar for her assistance in the design and conduct
of the literature search for this systematic review, Drs. Gordon Guyatt and Jason Busse for
their methodological advice, and Dr. Lawrence Mbuagbaw for biostatistical advice. Dr. John
You was supported by a Research Early Career Award from Hamilton Health Sciences.
Contributors: AJ and JJY conceived of and designed the study. JJY is guarantor. AJ, KQ, SC,
and AG screened titles, abstracts, and full-text articles for eligibility. AJ, DBV and JJY
extracted data from eligible articles. SC and JJY analyzed the data. All authors participated
in: interpretation of data, drafting of the manuscript, and gave final approval of the version
Page 22 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 23
to be published. All authors had full access to all of the data in the study and can take
responsibility for the integrity of the data and the accuracy of the data analysis.
Competing interests: All authors have completed the Unified Competing Interest form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author).
All authors declare that: they have no relationships with companies that might have an
interest in the submitted work in the previous 3 years; their spouses, partners, or children
have no financial relationships that may be relevant to the submitted work; and they have
no non-financial interests that may be relevant to the submitted work.
Ethics approval: Ethics approval was not required for this study.
Funding: This research received no specific grant from any funding agency in the public,
commercial or not-for-profit sectors.
Transparency declaration: JJY (the manuscript's guarantor) affirms that the manuscript
is an honest, accurate, and transparent account of the study being reported; that no
important aspects of the study have been omitted; and that any discrepancies from the
study as planned have been explained.
Data sharing: The study dataset is available from the corresponding author at
jyou@mcmaster.ca.
Page 23 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 24
FIGURE LEGENDS
Figure 1. Summary of article selection
Abbreviations: RCT, randomized controlled trial; ACP, advance care planning.
Figure 2. Risk of bias in eligible studies
Review authors’ judgements about each risk of bias item for each included study. Green
circles = low risk of bias; red circles = high risk of bias; empty boxes = unclear risk of bias.
Figure 3. Effect of video decision aids on patient preferences for cardiopulmonary
resuscitation
Effect of the video intervention in individual studies and the pooled effect across studies
from a random effects model are expressed as risk ratios and 95% confidence intervals. A
risk ratio less than 1.0 means that patients in the video arm were less likely to prefer
cardiopulmonary resuscitation compared to those in the control arm.
Figure 4. Effect of video decision aids on knowledge related to advance care
planning
Effect of the video intervention in individual studies and the pooled effect across studies
from a random effects model are expressed as standardized mean differences and 95%
confidence intervals. A standardized mean difference greater than zero means that
knowledge about advance care planning was greater for patients in the video arm
compared to those in the control arm.
Page 24 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 25
Figure 5. Effect of video decision aids on completion of advance directives
Effect of the video intervention in individual studies and the pooled effect across studies
from a random effects model are expressed as risk ratios and 95% confidence intervals. A
risk ratio greater than 1.0 means that patients in the video arm were more likely to
complete an advance directive compared to those in the control arm.
Page 25 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 26
REFERENCES
(1) Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate
decision making before death. N Engl J Med 2010;362:1211-1218.
(2) Sudore RL, Fried TR. Redefining the "planning" in advance care planning:
preparing for end-of-life decision making. Ann Intern Med 2010;153:256-261.
(3) Detering KM, Hancock AD, Reade MC, et al. The impact of advance care planning on
end of life care in elderly patients: randomised controlled trial. BMJ
2010;340:c1345.
(4) Wright AA, Zhang B, Ray A et al. Associations between end-of-life discussions,
patient mental health, medical care near death, and caregiver bereavement
adjustment. JAMA 2008;300:1665-1673.
(5) Mullick A, Martin J, Sallnow L. An introduction to advance care planning in
practice. BMJ 2013;347:f6064.
(6) Cook D, Rocker G, Heyland D. Enhancing the quality of end-of-life care in Canada.
CMAJ 2013;185:1383-1384.
(7) IOM (Institute of Medicine). Dying in America: Improving quality and honoring
individual preferences near the end of life. Washington, DC: The National
Academies Press; 2014.
(8) Stacey D, Legare F, Col NF et al. Decision aids for people facing health treatment or
screening decisions. Cochrane Database Syst Rev 2014;1:CD001431.
(9) Butler M, Ratner E, McCreedy E, et al. Decision aids for advance care planning: an
overview of the state of the science. Ann Intern Med 2014;161:408-418.
(10) Hostetter M, Klein S. Helping Patients Make Better Treatment Choices with
Decision Aids. Quality Matters. Available from: The Commonwealth Fund. Accessed
at http://www.commonwealthfund.org/Newsletters/Quality-
Matters/2012/October-November/In-Focus.aspx on February 4, 2014.
(11) Volandes AE, Barry MJ, Chang Y, et al. Improving decision making at the end of life
with video images. Med Decis Making 2010;30:29-34.
(12) Sun LH. Videos aim to inform patients about their medical options at the end of
life. The Washington Post. Accessed at
http://www.washingtonpost.com/national/health-science/videos-aim-to-inform-
patients-about-their-medical-options-at-the-end-of-life/2014/06/02/b0eae002-
c63f-11e3-8b9a-8e0977a24aeb_story.html on June 2, 2014.
Page 26 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 27
(13) Heyland DK, Frank C, Groll D et al. Understanding cardiopulmonary resuscitation
decision making: perspectives of seriously ill hospitalized patients and family
members. Chest 2006;130:419-428.
(14) Murphy DJ, Burrows D, Santilli S, et al. The influence of the probability of survival
on patients' preferences regarding cardiopulmonary resuscitation. N Engl J Med
1994;330:545-549.
(15) Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. www cochrane-handbook org [serial online] 2011;
Available from: The Cochrane Collaboration.
(16) Guyatt GH, Oxman AD, Kunz R, et al. What is "quality of evidence" and why is it
important to clinicians? BMJ 2008;336:995-998.
(17) Yamada R, Galecki AT, Goold SD, et al. A multimedia intervention on
cardiopulmonary resuscitation and advance directives. J Gen Intern Med
1999;14:559-563.
(18) El-Jawahri A, Podgurski LM, Eichler AF, et al. Use of video to facilitate end-of-life
discussions with patients with cancer: a randomized controlled trial. J Clin Oncol
2010;28:305-310.
(19) Volandes AE, Paasche-Orlow MK, Mitchell SL, et al. Randomized controlled trial of
a video decision support tool for cardiopulmonary resuscitation decision making
in advanced cancer. J Clin Oncol 2013;31:380-386.
(20) Epstein AS, Volandes AE, Chen LY, et al. A randomized controlled trial of a
cardiopulmonary resuscitation video in advance care planning for progressive
pancreas and hepatobiliary cancer patients. J Palliat Med 2013;16:623-631.
(21) Volandes AE, Brandeis GH, Davis AD, et al. A randomized controlled trial of a goals-
of-care video for elderly patients admitted to skilled nursing facilities. J Palliat Med
2012;15:805-811.
(22) Volandes AE, Paasche-Orlow MK, Barry MJ, et al. Video decision support tool for
advance care planning in dementia: randomised controlled trial. BMJ
2009;338:b2159.
(23) Volandes AE, Ferguson LA, Davis AD, et al. Assessing End-of-Life Preferences for
Advanced Dementia in Rural Patients Using an Educational Video: A Randomized
Controlled Trial. J Palliat Med 2011;14:169-177.
(24) Siegert EA, Clipp EC, Mulhausen P, et al. Impact of advance directive videotape on
patient comprehension and treatment preferences. Arch Fam Med 1996;5:207-
212.
Page 27 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
May 3, 2015 28
(25) Landry FJ, Kroenke K, Lucas C, et al. Increasing the use of advance directives in
medical outpatients. J Gen Intern Med 1997;12:412-415.
(26) Brown JB, Beck A, Boles M, et al. Practical methods to increase use of advance
medical directives. J Gen Intern Med 1999;14:21-26.
(27) O'Connor AM. Validation of a decisional conflict scale. Med Decis Making
1995;15:25-30.
(28) Fried TR, Bullock K, Iannone L, O'Leary JR. Understanding advance care planning
as a process of health behavior change. J Am Geriatr Soc 2009;57:1547-1555.
(29) Sudore RL, Stewart AL, Knight SJ et al. Development and validation of a
questionnaire to detect behavior change in multiple advance care planning
behaviors. PLoS One 2013;8:e72465.
(30) Sudore RL, Knight SJ, McMahan RD et al. A Novel Website to Prepare Diverse Older
Adults for Decision Making and Advance Care Planning: A Pilot Study. J Pain
Symptom Manage 2014;47:674-86.
(31) Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009;151:264-
9.
(32) Schulz KF, Grimes DA. Allocation concealment in randomised trials: defending
against deciphering. Lancet 2002;359:614-18.
(33) Heyland DK, Tranmer J, Feldman-Stewart D. End-of-life decision making in the
seriously ill hospitalized patient: an organizing framework and results of a
preliminary study. J Palliat Care 2000;16 Suppl:S31-S39.
Page 28 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 1
117x127mm (300 x 300 DPI)
Page 29 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 2
230x559mm (300 x 300 DPI)
Page 30 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 3
54x16mm (300 x 300 DPI)
Page 31 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 4
38x8mm (300 x 300 DPI)
Page 32 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
Figure 5
43x10mm (300 x 300 DPI)
Page 33 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
1
Web Appendix 1. Detailed description of literature search strategy
The following search strategy was used for Medline and was adapted for CENTRAL, EMBASE, PsycInfo, AMED and CINAHL.
Database: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1980 to Present> -------------------------------------------------------------------------------- 1. Videotape Recording/ 2. video*.mp. 3. (VHS or DVD* or blue-ray disc* or Compact Disc* or CDs or audiovisual).mp. 4. ((interactive or digital) adj5 media).mp. 5. or/1-4 6. exp advance care planning/ or life support care/ or palliative care/ or exp terminal care/ or advance directives/ or living will/ 7. (Advance Care Planning or ACP or care at the end of life initiative or CEOL or Goals of care or GCD or end of life or living will*).mp. 8. or/6-7 9. exp Resuscitation/ 10. Resuscitat*.mp. 11. CPR.mp. 12. exp Respiration, Artificial/ 13. (Ventilator* or Ventilation*).mp. 14. exp Ventilators, Negative-Pressure/ 15. (bilevel positive airway pressure or BiPAP or BPAP).mp. 16. (positive pressure* or positivepressure*).mp. 17. (Respiratory or Respiration*).mp. 18. exp Intubation/ 19. Airway Management/ 20. (intubate* or intubation).mp. 21. Esophageal.mp. 22. (Laryngeal mask or LMA).mp. 23. (Tracheostom* or Tracheotom*).mp. 24. Enteral Nutrition/ 25. ((enter* or nasogastric or NG) adj5 (feed* or nutrition* or immunonutrition*)).mp. 26. nasoduodenal tube*.mp. 27. Feeding Methods/ 28. exp Parenteral Nutrition/ 29. ((Parenteral* or intravenous) adj3 (feeding* or nutrition)).mp. 30. (TPN or PN).mp. 31. ((Nasogastric or NG or gastrostomy or jejunostomy or gastric or orogastric or nasoenteric or nasojejunal or nasointestinal or transabdominal) adj3 (intubat* or tube* or feed*)).mp. 32. ((artificial or force or tube) adj3 (feeding* or nutrition)).mp. 33. tube feeding/
Page 34 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
2
34. (Percutaneous endoscopic gastrostomy or PPEG).mp. 35. ((RIG or PEG) and (Percutaneous or endoscopic or gastrostomy)).mp. 36. exp Renal Replacement Therapy/ 37. Kidney, Artificial/ or artificial kidney*.mp. 38. (dialyzer or hemodialysis or dialysis).mp. 39. Critical Care/ 40. Critical Illness/ 41. exp Intensive Care Units/ 42. ICU*.mp. 43. ((critical or intensive) adj3 (care or illness)).tw. 44. (ACLS or Advanced cardiovascular life support).mp. 45. Defibrillation.mp. 46. or/9-45 47. exp Patient Satisfaction/ or patient centered care/ or exp choice behavior/ or attitude to health/ or attitude to death/ or personal autonomy/ or patient participation/ or patient education as topic/ 48. ((patient* or Individual* or caregiver* or care-giver*) adj10 (wish* or value* or desire* or desirability or selection or prefer* or decide* or decision* or choice* or chose* or want* or participat*)).mp. 49. exp Decision Making/ or Decision Support Techniques/ or decision aid*.mp. 50. exp Patients/ or patient*.mp. or caregivers/ or caregiver*.mp. or care-giver*.mp. 51. 49 and 50 52. 47 or 48 or 51 53. 5 and 8 54. 5 and 46 and 52 55. 53 or 54 ***************************
Life-sustaining treatments of interest:
1. Cardiopulmonary resuscitation (CPR) 2. Mechanical ventilation 3. Respirator 4. Ventilator 5. Endotracheal intubation 6. Enteral feeding 7. Enteral nutrition 8. Total parenteral nutrition 9. Nasogastric tube feeding 10. Tube feeding 11. Percutaneous endoscopic gastrostomy (PEG) tube 12. Hemodialysis 13. Dialysis 14. Intensive care unit
Page 35 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
3
15. Critical care unit 16. Advanced cardiac life support (=ACLS) 17. Advanced cardiovascular life support (=ACLS) 18. Defibrillation 19. Cardiac defibrillation
Page 36 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. P
rotected by copyright.http://bm
jopen.bmj.com
/B
MJ O
pen: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. D
ownloaded from
For peer review only
PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Section/topic # Checklist item Reported on page #
TITLE
Title 1 Identify the report as a systematic review, meta-analysis, or both. 1
ABSTRACT
Structured summary 2 Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.
3-4
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of what is already known. 6
Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
6-7
METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number.
7
Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered,
language, publication status) used as criteria for eligibility, giving rationale. 7-8
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.
7
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
Web Appendix
Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).
8-9
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.
8-9
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.
7-9
Risk of bias in individual studies
12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
8
Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 9-10
Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency
(e.g., I2) for each meta-analysis.
9-10
Page 37 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Page 1 of 2
Section/topic # Checklist item Reported on page #
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
--
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.
16
RESULTS
Study selection 17 Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
Fig 1
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citations.
Table 1
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). p.11; Figure 2
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
p. 16-18; Figs 3-5
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. p. 16-18; Figs 3-5
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). --
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). 16
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers).
18-21
Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).
19
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 18-21
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.
22
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit: www.prisma-statement.org.
Page 38 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from
For peer review only
PRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 ChecklistPRISMA 2009 Checklist
Page 2 of 2
Page 39 of 39
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open
123456789101112131415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960
on April 8, 2020 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007491 on 24 June 2015. Downloaded from