Advanced care planning (ACP) in the COVID-19 Era: Lessons Learned, a rapid review

Aims: Amidst COVID-19, where older persons bear significant mortality and morbidity, ACP has been highlighted. We sought to explore lessons learned in relation to ACP in this pandemic, in particular, barriers and enablers of ACP in the older population.

Methods: We searched MEDLINE and PubMed for “advance care planning/advance directive” and “COVID-19” (MeSH) to identify relevant literature in English. We screened references from identified articles.

Results: 75 papers met eligibility criteria. Preliminary results indicate that positive themes included COVID-19 provides an opportunity to initiate ACP conversations and improve ACP rates across the community. The accelerated implementation of tele-communication and videoconferencing has facilitated ACP. The responsibility of ACP is now being shared by doctors and other health professionals. However, ACP engagement among older persons remains low, especially among minority groups and those with limited health literacy. New barriers to ACP included physical distancing and visitor restrictions. The sudden deterioration often seen with COVID-19 can leave patients alone, incapacitated and unable to voice their wishes around ACP. Substitute decision makers experience loss of control and disempowerment due to isolation from family members with COVID-19. Mistrust was reported, particularly around rationing of healthcare resources.

Conclusions: While technological advances have facilitated ACP in the COVID-19 era, new barriers to ACP, due to isolation have also emerged. Without proactive and early ACP, ongoing pandemic restrictions may further disadvantage vulnerable groups during critical illness. We risk subjecting our older patients to aggressive and non-beneficial treatments, potentially contrary to the individual’s values and preferences.