Designing a Pragmatic Advance Care Planning Group Visit Intervention for Individuals with Mild Cognitive Impairment

ANDREA E. DADDATO, MS, MS
Professional Research Assistant, PhD Candidate, Division of Geriatric Medicine, University of Colorado School of Medicine

Among older adults without cognitive impairment, a novel advance care planning group visit (ACP-GV) intervention increased ACP documentation and readiness to engage in ACP. For individuals with mild cognitive impairment (MCI), planning for their future medical wishes and values of importance before further cognitive decline is important. A key question is whether a pragmatic intervention can be adapted to support people with MCI and their family care partners.

Individuals with MCI and study partners recruited as dyads from an academic healthcare system in Aurora, Colorado.

To design for pragmatic implementation, we used a human-centered design process, rapid-cycle prototyping, and qualitative methods guided by the frameworks of the NIH Stage Model for Behavioral Intervention Development to adapt an ACP-GV intervention to individuals with MCI and their study partners (dyads).1,2 We convened a longitudinal cohort of six dyads in three focus groups to suggest adaptations. We also conducted a single arm study of four ACP-GV prototypes (n=13 dyads total) that were iteratively refined with adaptations from the longitudinal cohort and participant feedback. We used interviews after each prototype to gather feedback.

Six dyads met three times from February-October 2019 to discuss intervention adaptations, such as what ACP decision tools should be used and what outcomes would be meaningful for an ACP-GV intervention adapted for individuals with MCI. Stakeholder feedback informed four n-of-1 adapted ACP-GV interventions with an average of 3.25 dyads per group visit. Following the completion of each ACP-GV, 20 participants were interviewed for feedback of whether the intervention met their expectations and goals related to ACP, effectiveness of the tools/resources, format of the intervention, and recommendations for future ACP-GVs. Feedback from the interviews were reported back to the longitudinal focus group for further input. Overall, interviewees found the group visit setting helpful to hear others perspectives and to initiate tough conversations about end-of-life planning. Most felt the size of the ACP-GVs were appropriate, the videos and resources were helpful, and would recommend the intervention to others. The longitudinal focus group reported ACP as a priority for individuals with MCI and described the need for ACP in a group setting. An additional theme was to include candid conversation about the diagnosis of MCI and how it relates to the need for ACP.

Use of a pragmatic research approach with rapid prototyping and stakeholder engagement allowed testing of different resources and tools aimed at helping individuals with MCI and their partners discuss ACP. Future work is needed to understand the feasibility of implementing an ACP-GV intervention for individuals with MCI into clinical settings.