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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 1 Participants' quality of life (overall analysis: EQ‐5D, Kansas City Cardiomyopathy Questionnaire).
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Analysis 1.1

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 1 Participants' quality of life (overall analysis: EQ‐5D, Kansas City Cardiomyopathy Questionnaire).

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 2 Participants' quality of life (subgroup analysis by follow‐up periods: EQ‐5D, Kansas City Cardiomyopathy Questionnaire).
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Analysis 1.2

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 2 Participants' quality of life (subgroup analysis by follow‐up periods: EQ‐5D, Kansas City Cardiomyopathy Questionnaire).

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 3 Completion of documentation by medical staff regarding discussions with participants about ACP processes.
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Analysis 1.3

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 3 Completion of documentation by medical staff regarding discussions with participants about ACP processes.

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 4 Participants' depression (overall analysis).
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Analysis 1.4

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 4 Participants' depression (overall analysis).

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 5 Participants' depression (subgroup analysis by follow‐up periods).
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Analysis 1.5

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 5 Participants' depression (subgroup analysis by follow‐up periods).

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 6 Participants' decisional conflict.
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Analysis 1.6

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 6 Participants' decisional conflict.

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 7 All‐cause mortality.
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Analysis 1.7

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 7 All‐cause mortality.

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Comparison 1 Advance care planning (ACP) versus usual care, Outcome 8 All‐cause mortality (sensitivity analysis excluding Kirchhoff 2010).
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Analysis 1.8

Comparison 1 Advance care planning (ACP) versus usual care, Outcome 8 All‐cause mortality (sensitivity analysis excluding Kirchhoff 2010).

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Summary of findings for the main comparison. Advance care planning compared with usual care for patients with heart failure

Advance care planning compared with usual care for patients with heart failure

Patient or population: people with heart failure with or without their surrogate decision‐makers/carers

Settings: inpatient and outpatient hospitals and clinics

Intervention: ACP

Comparison: usual care

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care

ACP

Concordance between participants' preferences and end‐of‐life care (yes/no)

Post‐death data: mean days to death, ACP group (388.8 ± 255.7);
usual care group (362.2 ± 288.4)

625 per 1000

744 per 1000
(569 to 969)

RR 1.19 (0.91 to 1.55)

110
(1 RCT)

⊕⊝⊝⊝
Very lowa,b

—

Participants' quality of life

Measured by EQ‐5D and KCCQ.

Higher scores indicate high‐quality of life.

Follow‐up: 2 weeks to 6 months

The quality of life score in the ACP groups was on average 0.06 SDs higher (0.26 lower to 0.38 higher) than in the usual care groups.

—

156
(3 RCTs)

⊕⊕⊝⊝
Lowc,d

1 additional study reported quality of life using the MLHF Questionnaire.

The study showed that the quality of life score was improved by 14.86 points in the intervention group compared with 11.80 points in the usual care group at 3 months.

Generally, 0.2 SD represents a small difference, 0.5 moderate, and 0.8 large.

Patients' satisfaction with care/treatment (yes/no)

—

—

—

—

—

Outcome not reported.

Completion of documentation by medical staff regarding discussions with participants about ACP processes (yes/no)

Follow‐up: 3–6 months

489 per 1000

822 per 1000
(602 to 1000)

RR 1.68 (1.23 to 2.29)

92
(2 RCTs)

⊕⊕⊝⊝
Lowc,e

1 additional study reported completion of documentation with HR (HR 2.87, 95% CI 1.09 to 7.59; P = 0.033).

Participants' depression

Measured on PHQ‐8, PHQ‐9, and HADS. Higher scores indicate high depression

Follow‐up: 2 weeks to 6 months

The depression score in the ACP groups was on average 0.58 SDs (0.82 to 0.34) lower than in the usual care groups.

—

278
(3 RCTs)

⊕⊕⊝⊝

Lowc,e

Generally, 0.2 SD represents a small difference, 0.5 moderate, and 0.8 large.

Caregivers' satisfaction with care/treatment (yes/no)

—

—

—

—

—

Outcome not reported.

Quality of communication

Measured on Quality of Patient‐Clinician Communication About End‐of‐Life Care. Higher score indicates high satisfaction with the quality of communication

Assessed after intervention

11.2 ± 0.8 (mean ± SD)

MD 0.4 lower

(1.61 lower to 0.81 higher)

—

9
(1 RCT)

⊕⊝⊝⊝
Very lowb,f

—

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

ACP: advanced care planning; CI: confidence interval; EQ‐5D: EuroQol‐5D; HADS: Hospital Anxiety and Depression Survey; HR: hazard ratio; KCCQ: Kansas City Cardiomyopathy Questionnaire; MD: mean difference; MLHF: Minnesota Living with Heart Failure; PHQ: Patient Health Questionnaire; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation; SMD: standardised mean difference.

GRADE Working Group grades of evidence
High‐quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate‐quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low‐quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low‐quality: we are very uncertain about the estimate.

aDowngraded one level for indirectness because the study included participants other than people with heart failure.

bSince the outcome included only one study, the sample size was too small, and had wide confidence intervals. Therefore, we downgraded two levels for imprecision.

cDowngraded one level for risk of bias because most included studies showed unclear selection bias and high attrition bias.

dDowngraded one level for imprecision due to small sample size and wide confidence intervals.

eDowngraded one level for imprecision due to small sample size.

fDowngraded one level for risk of bias due to high risk of selection bias.

Figuras y tablas -
Summary of findings for the main comparison. Advance care planning compared with usual care for patients with heart failure
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Comparison 1. Advance care planning (ACP) versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Participants' quality of life (overall analysis: EQ‐5D, Kansas City Cardiomyopathy Questionnaire) Show forest plot

3

156

Std. Mean Difference (Fixed, 95% CI)

0.06 [‐0.26, 0.38]

2 Participants' quality of life (subgroup analysis by follow‐up periods: EQ‐5D, Kansas City Cardiomyopathy Questionnaire) Show forest plot

3

156

Std. Mean Difference (Fixed, 95% CI)

0.06 [‐0.26, 0.38]

2.1 Follow‐up periods ≤ 3 months

1

44

Std. Mean Difference (Fixed, 95% CI)

‐0.05 [‐0.65, 0.54]

2.2 Follow‐up periods > 3 months

2

112

Std. Mean Difference (Fixed, 95% CI)

0.11 [‐0.27, 0.48]

3 Completion of documentation by medical staff regarding discussions with participants about ACP processes Show forest plot

2

92

Risk Ratio (M‐H, Fixed, 95% CI)

1.68 [1.23, 2.29]

4 Participants' depression (overall analysis) Show forest plot

3

278

Std. Mean Difference (Fixed, 95% CI)

‐0.58 [‐0.82, ‐0.34]

5 Participants' depression (subgroup analysis by follow‐up periods) Show forest plot

3

278

Std. Mean Difference (Fixed, 95% CI)

‐0.58 [‐0.82, ‐0.34]

5.1 Follow‐up periods ≤ 3 months

1

167

Std. Mean Difference (Fixed, 95% CI)

‐0.69 [‐1.01, ‐0.38]

5.2 Follow‐up periods > 3 months

2

111

Std. Mean Difference (Fixed, 95% CI)

‐0.41 [‐0.79, ‐0.03]

6 Participants' decisional conflict Show forest plot

2

38

Mean Difference (IV, Fixed, 95% CI)

‐0.26 [‐0.55, 0.02]

7 All‐cause mortality Show forest plot

5

795

Risk Ratio (M‐H, Fixed, 95% CI)

1.32 [1.04, 1.67]

8 All‐cause mortality (sensitivity analysis excluding Kirchhoff 2010) Show forest plot

4

482

Risk Ratio (M‐H, Fixed, 95% CI)

1.44 [0.99, 2.09]
Figuras y tablas -
Comparison 1. Advance care planning (ACP) versus usual care
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