Advance directives in European long-term care facilities: a cross-sectional survey

PACE consortium, Paula Andreasen, Ulla Harriet Finne-Soveri, Luc Deliens, Lieve Van den Block, Sheila Payne, Giovanni Gambassi, Bregje D Onwuteaka-Philipsen, Tinne Smets, Eero Lilja, Violetta Kijowska, Katarzyna Szczerbińska

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BACKGROUND: End-of-life care practices in long-term care facilities (LTCFs) are the focus of growing attention in Europe, due to rapidly increasing number of older persons living in LTCFs. The knowledge about end-of-life discussions or existence of written advance directives in the European LTCFs is scarce. This study's aim is to investigate the prevalence of written advance directives and their sociodemographic associates, among recently deceased LTCF residents, in six European countries.

METHODS: Data from the European Union-funded PACE database were collected from 322 LTCFs in six European countries in 2014. The assessments were performed by using two questionnaires designed for LTCF administrative staff and for staff member.LTCFs were selected within each country by using proportional stratified random sampling procedure. Facilities with certain types and sizes were included from each country.Multilevel multivariate analyses were performed to evaluate associations between written advance directives and selected predictors.

RESULTS: In total, 32.5 % of the 1384 deceased LTCF residents had a written advance directive with a range from 0% to 77 % between countries. The proportion of the most common advance directive, 'Do not resuscitate in case of cardiac or respiratory arrest (DNR)', varied correspondingly from 0% to 75%.LTCF type (OR 2.86 95% CI 1.59 to 5.23) and capability of expressing at the time of admission (OR 3.26 95% CI 2.26 to 4.71) were the independent predictors for advance directive. Residents living in LTCFs where physician was available were less likely to have advance directive compared with residents from LTCFs where physician was not available.

CONCLUSION: Extensive differences for prevalence of written advance directive exist between countries among older LTCF residents in Europe. Timely and appropriate response to LTCF resident's health needs and preferences efforts advance care planning.

Original languageEnglish
Pages (from-to)E393-E402
Number of pages10
JournalBMJ Supportive and Palliative Care
Issue numbere3
Early online date2019
Publication statusPublished - 1 Aug 2019

Bibliographical note

Funding Information:
Efforts to define and standardise ACP have been promoted by a Delphi study which proposed an international definition (2017) supported by European Association for Palliative Care.

Publisher Copyright:
© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Copyright 2022 Elsevier B.V., All rights reserved.


  • advance directives
  • hospice and palliative care nursing
  • living wills
  • long-term care
  • palliative care


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