Motivational Interviewing to Enhance Advance Care Planning for Older Adults and Caregivers After Emergency Visits

Motivational Interviewing to Enhance Advance Care Planning for Older Adults and Caregivers After Emergency Visits

Maximizing Teachable Moments: Motivational Interviewing (MI) to Enhance Advance Care Planning (ACP) for Older Adults and Caregivers After Emergency Visits - A Mixed-Method Randomized Controlled Trial

This study aims to evaluate the effectiveness of a motivational interviewing (MI) intervention in enhancing advance care planning (ACP) among older adults who have visited the Emergency Room (ER) in the past six months and their family caregivers. The main question it aims to answer is: The effectiveness of the MI-based ACP intervention implemented within six months of an ER visit on improving older adults' advance directives (AD) completion rate. Compared to participants in the control group who will only receive a self-education booklet, participants in the intervention group will receive a motivational interview educational intervention to see the effectiveness of an MI-based ACP intervention implemented within six months following an emergency room visit regarding the completion of AD for older adults.

Targeted issue: At present no feasible method exists to empower older adults following ER visits to engage in ACP in Hong Kong. Population: The target group will be dyads comprising older adults who have had ER visits within the previous six months and their family caregivers. Intervention: An MI-based ACP intervention our team developed. Main study aim: To investigate the effectiveness of an MI-based ACP intervention implemented within six months following an emergency room visit on completion of AD for older adults compared to a self-education group. Study method: Investigators will recruit eligible participants from two largest public hospitals, including the geriatric outpatient clinic of Queen Mary Hospital (IRB Ref: UW23-402) and the accident & emergency department of Queen Elizabeth Hospital (IRB Ref: KC/KE-23-0058/ER-1). A parallel RCT (allocation ratio= 1:1) with a post-trial qualitative study will be adopted and three follow-up time points at 3-, 6- and 12-month post-intervention. Participants in the intervention group will receive a motivational interview educational intervention, while participants in the comparison group will receive the pictorial ACP educational booklet for self-learning only. Completion of AD and health service utilization will be assessed at three follow-up time points. In addition, a post-intervention interview, regarding stakeholders' views on the relevance, effectiveness, and experience of the intervention., will be conducted.

Older adult-family member dyads in this arm will receive an MI-based education intervention our team developed.

Older adult-family member dyads in this arm will receive a self-learning ACP educational material developed by the Hong Kong Hospital Authority.

Motivational Interviewing on Advance Care Planning Intervention: Dyads of older adults and family caregivers will receive three MI-based ACP counselling sessions: (1) a preparatory session, (2) motivation session, and (3) planning session. The preparatory session will take 10-15 minutes, and the following two sessions in weeks 2 and 3 will last 30-45 minutes each. Before each session, the nurse interventionist will first assess the dyad's readiness to engage in ACP based on the state of change algorithm. Participants who have never thought about ACP will be in the pre-contemplation state, those who are willing to discuss EOL care and preferences to be in the contemplation state, those ready to talk about EOL planning to be in the preparation state, and those in the action state have a confirmed action plan on signing up their ADs. Readiness-based ACP goals will be established, and state-matched MI counseling will be customized for each participant.

Completion of AD documentation will be measured by reviewing participants' medical records for a new AD document or self-reported AD completion at the 3-month follow-up time point.

Completion of AD documentation will be measured by reviewing participants' medical records for a new AD document or self-reported AD completion at the 6-month follow-up time point.

Completion of AD documentation will be measured by reviewing participants' medical records for a new AD document or self-reported AD completion at the 12-month follow-up time point.

The target group will be dyads comprising older adults who have had ER visits within the previous six months and their family caregivers. A dyad is defined as one older adult and one primary family caregiver of the older adult. For older adults: Inclusion Criteria: Aged 65 or older At least one episode of ER visit in the last six months Has a family caregiver to be present during the intervention Able to communicate in Chinese Exclusion Criteria: Has completion of an AD Moderate to severe cognitive impairment or diagnosis of dementia, as identified in health records Communication problems (e.g., deafness or aphasia) For family caregivers: Inclusion Criteria: Aged 18 or above Immediate or extended family member or friend nominated by an eligible older adult participant as primary caregiver Able to communicate in Chinese Exclusion Criteria: Moderate to severe cognitive impairment Communication problems (e.g., deafness or aphasia)