***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND A large discrepancy exists between the wishes of dying patients and their actual end-of-life care . However , retrospective clinical experience suggests that early advance care planning ( ACP ) can markedly reduce this discrepancy . This article describes a r and omized trial to evaluate the short-term clinical utility of early ACP . We also assessed the feasibility of performing a larger prospect i ve study to document long-term outcomes . METHODS Ambulatory geriatric patients ( N = 61 ) were r and omized to either a  control group , which received only a Massachusetts Health Care Proxy form to complete , or an intervention group , in which each patient and health care agent discussed ACP with a trained nurse facilitator . The benefits and burdens of life-sustaining treatments were discussed , and patient goals and preferences for these treatments were documented . RESULTS Two-month follow-up revealed that the intervention achieved higher congruence between agents and patients in their underst and ing of patients ' end-of-life care preferences , with 76 % ( 19/25 ) in complete agreement vs 55 % ( 12/22 ) of the controls ( effect size [ ES ] = -0.43 ) . There was also a greater increase in patient knowledge about ACP in the intervention group ( ES = 0.22 ) . Intervention patients became less willing to undergo life-sustaining treatments  for a new serious medical problem ( ES = -0.25 ) , more willing to undergo such treatments for an incurable progressive disease ( ES = 0.24 ) , and less willing to tolerate poor health states ( ES = -0.78 ) . Practical insights were gained about how to conduct a larger study more effectively . CONCLUSION A facilitated discussion about end-of-life care between patients and their health care agents helps define and document the patient 's wishes for both patient and agent BACKGROUND National guidelines recommend that physicians discuss end-of-life ( EOL ) care planning with patients with cancer whose life expectancy is less than 1 year . OBJECTIVE To evaluate the incidence of EOL care discussion s for patients with stage IV lung or colorectal cancer and where , when , and with whom these discussion s take place . DESIGN Prospect i ve cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005 . SETTING Participants lived in Northern California , Los Angeles County , North Carolina , Iowa , or Alabama or received care in 1 of 5 large HMOs or 1 of 15 Veterans Health Administration sites . PATIENTS 2155 patients with stage IV lung or colorectal cancer . MEASUREMENTS End-of-life care discussion s reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis . RESULTS 73 % of patients had EOL care discussion s identified by at least 1 source . Among the 1470 patients who died during follow-up , 87 % had EOL care discussion s , compared with 41 % of the 685 patients who were alive at the end of follow-up . Of the 1081 first EOL care discussion s documented in records , 55 % occurred in the hospital . Oncologists documented EOL care discussion s with only 27 % of their patients . Among 959 patients with documented EOL care discussion s who died during follow-up , discussion s took place a median of 33 days before death . LIMITATIONS The depth and quality of EOL care discussion s was not evaluated . Much of the information about discussion s came from surrogates of patients who died before baseline interviews could be obtained . CONCLUSION Although most patients with stage IV lung or colorectal cancer discuss EOL  care planning with physicians before death , many discussion s occur during acute hospital care , with providers other than oncologists , and late in the course of illness . PRIMARY FUNDING SOURCE National Cancer Institute and Department of Veterans Affairs Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more CONTEXT There are few r and omized controlled trials on the effectiveness of palliative care interventions to improve the care of patients with advanced cancer . OBJECTIVE To determine the effect of a nursing-led intervention on quality of life , symptom intensity , mood , and re source use in patients with advanced cancer . DESIGN , SETTING , AND PARTICIPANTS R and omized controlled trial conducted from November 2003 through May 2008 of 322 patients with advanced cancer in a rural , National Cancer Institute- design ated comprehensive cancer center in New Hampshire and affiliated outreach clinics and a VA medical center in Vermont . INTERVENTIONS A multicomponent , psychoeducational intervention ( Project ENABLE [ Educate , Nurture , Advise , Before Life Ends ] ) conducted by advanced practice nurses consisting of 4 weekly educational sessions and monthly follow-up sessions until death or study completion ( n = 161 ) vs usual care ( n = 161 ) . MAIN OUTCOME MEASURES Quality of life was measured by the Functional Assessment of Chronic Illness Therapy for Palliative Care ( score range , 0 - 184 ) . Symptom intensity was measured by the Edmonton Symptom Assessment Scale ( score range , 0 - 900 ) . Mood was measured by the Center for Epidemiological Studies Depression Scale ( range , 0 - 60 ) . These measures were assessed at baseline , 1 month , and every 3 months until death or study completion . Intensity of service was measured as the number of days in the hospital and in the intensive care unit ( ICU ) and the number of emergency department visits recorded in the electronic medical record . RESULTS A total of 322 participants with cancer of the gastrointestinal tract ( 41 % ; 67 in the usual care group vs 66 in the intervention group ) , lung ( 36 % ; 58 vs 59 ) , genitourinary tract ( 12 % ; 20 vs 19 ) , and breast ( 10 % ; 16 vs 17 ) were r and omized . The estimated treatment effects ( intervention minus usual care ) for all participants were a mean ( SE ) of 4.6 ( 2 ) for quality of life ( P = .02 ) , -27.8 ( 15 ) for symptom intensity ( P = .06 ) , and -1.8 ( 0.81 ) for depressed mood ( P = .02 ) . The estimated treatment effects in participants who died during the study were a mean ( SE ) of 8.6 ( 3.6 ) for quality of life ( P = .02 ) , -24.2 ( 20.5 ) for symptom intensity ( P = .24 ) , and -2.7 ( 1.2 ) for depressed mood ( P = .03 ) . Intensity of service did not differ between the 2 groups . CONCLUSION Compared with participants receiving usual oncology care , those receiving a nurse-led , palliative care-focused intervention addressing physical , psychosocial , and care coordination provided concurrently with oncology care had higher scores for quality of life and mood , but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or emergency department visits . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00253383 The prevalence of and mortality from chronic kidney disease ( CKD ) are high among African Americans .  Interventions to improve knowledge of the likely illness course and the benefits and risks of life-sustaining treatment at the end-of-life are needed for African Americans with CKD and their surrogate decision makers . Nineteen African Americans with stage 5 CKD and their surrogates were r and omized to either patient-centered advance care planning ( PC-ACP ) or usual care . PC-ACP dyads showed greater improvement in congruence in end-of-life treatment preferences ( p < .05 ) and higher perceived quality of communication ( p < .05 ) than do control dyads , but the two groups did not differ on other primary outcomes or acceptability measures , such as perceptions of cultural appropriateness . At posttest , 80 % of patients in the intervention group reported that they would choose to continue all life-sustaining treatments in a situation of a low chance of survival , whereas 28.6 % of patients in the control group reported that they would make that choice . At posttest , 90 % of patients in the intervention group reported that they would choose to undergo cardiopulmonary resuscitation  even if the chance of surviving the attempt would be low , whereas 57 % of patients in the control group reported that they would make that choice . PC-ACP can be effective in improving patient and surrogate congruence in end-of-life treatment preferences . However , the results suggest a need for further improvements in the intervention to enhance cultural appropriateness for African Americans with CKD Objective To investigate the impact of advance care planning on end of life care in elderly patients . Design Prospect i ve r and omised controlled trial . Setting Single centre study in a university hospital in Melbourne , Australia . Participants 309 legally competent medical in patients aged 80 or more and followed for six months or until death . Interventions Participants were r and omised to receive usual care or usual care plus facilitated advance care planning . Advance care planning aim ed to assist patients to reflect on their goals , values , and beliefs ; to consider future medical treatment preferences ; to appoint a surrogate ; and to document their wishes . Main outcome measures The primary outcome was whether a patient ’s end of life wishes were known and respected . Other outcomes included patient and family satisfaction with hospital stay and levels of stress , anxiety , and depression in relatives of patients who died . Results 154 of the 309 patients were r and omised to advance care planning  , 125 ( 81 % ) received advance care planning , and 108 ( 84 % ) expressed wishes or appointed a surrogate , or both . Of the 56 patients who died by six months , end of life wishes were much more likely to be known and followed in the intervention group ( 25/29 , 86 % ) compared with the control group ( 8/27 , 30 % ; P<0.001 ) . In the intervention group , family members of patients who died had significantly less stress ( intervention 5 , control 15 ; P<0.001 ) , anxiety ( intervention 0 , control 3 ; P=0.02 ) , and depression ( intervention 0 , control 5 ; P=0.002 ) than those of the control patients . Patient and family satisfaction was higher in the intervention group . Conclusions Advance care planning improves end of life care and patient and family satisfaction and reduces stress , anxiety , and depression in surviving relatives . Trial registration Australian New Zeal and clinical trials registry ACTRN12608000539336 Context Providing care for patients with dementia can pose enormous burdens that may be eased with assistance and support . Needs may differ by race or ethnicity . Contributions The investigators r and omly assigned Hispanic , black , and white dementia caregivers to receive written educational material s or an intensive intervention to improve caregiver quality of life .  The specific interventions were determined by caregivers , were delivered via trained personnel and telephone support groups , and targeted several dimensions of need . The study found that quality of life improved for Hispanic and white caregivers and for black spousal caregivers in the intervention group but not in the control group . The intervention had no detectable effect on the number of care recipients who were institutionalized . Caution s The study used only a single 6-month follow-up assessment , combined heterogeneous cultures and ethnicities into 3 groups , and excluded some ethnicities . Implication s An intensive intervention targeting several dimensions of caregiver need improved caregiver quality of life without an apparent effect on care recipient institutionalization . The effect did not differ by caregiver race or ethnicity . The Editors Caring for a family member with dementia is extremely stressful , contributes to psychiatric and physical illness , and increases the risk for death ( 1 , 2 ) . The accumulating evidence on the personal , social , and health effects of dementia caregiving has generated a broad range of intervention studies , including r and omized trials aim ed at decreasing the burden and stress of caregiving . Several studies have demonstrated statistically significant effects in reducing caregiver burden , lowering caregiver depression , and delaying institutionalization of care recipients ( 1 , 3 , 4 ) through either targeted interventions that treat a specific caregiver problem , such as depression , or broad-based multicomponent interventions that include counseling , case management , and telephone support . Persistent limitations of caregiver intervention research are the paucity of well-controlled r and omized trials , the limited range of outcomes examined , small sample sizes and insufficient power , geographic limitations , inadequate racial or ethnic variation , and a scarcity of comprehensive multicomponent interventions ( 4 ) . Indeed , none of the 41 r and omized clinical trials published in the last 5 years met Consoli date d St and ards of Reporting Trials ( CONSORT ) recommendations for reporting r and omized trials ( 5 ) , and many have serious method ologic problems that call into question the reported findings ( 4 ) . To address these limitations , the National Institute on Aging and the National Institute of Nursing Research funded a multisite research program design ed to develop and test an effective caregiver intervention : the Re sources for Enhancing Alzheimer 's Caregiver Health ( REACH ) study . We performed the study in 2 phases . In the first phase ( REACH I ) , we tested several different interventions at 6 U.S. sites to identify the most promising approaches to decreasing  caregiver burden and depression ( 6 ) . Results from the study showed that active treatments were superior to control conditions in reducing caregiver burden and that active engagement in skills training statistically significantly reduced  caregiver depression ( 7 , 8) . The existing literature and findings from REACH I helped guide the design of the REACH II intervention ( 7 , 8) . We based 
    Output:
    
We found that there is a low level of evidence that  RC and derivative models increase the incidence and prevalence of Advance Directive and Physician Orders for Life-Sustaining Treatment completion .
There is a high level of evidence that RC and derivative models  increase patient – surrogate congruence in Caucasian population s. The evidence is mixed , inconclusive , and too poor in quality to determine whether RC and derivative models change the consistency of treatment with wishes and overall health-care utilization in the end of life .