***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: OBJECTIVE Little is known about the effectiveness of advance care planning in the United Kingdom , although policy documents recommend that it should be available to all those with life-limiting illness . METHOD An exploratory patient preference r and omized controlled trial of advance care planning discussion s with an independent mediator ( maximum three sessions ) was conducted in London outpatient oncology clinics and a nearby hospice . Seventy-seven patients ( mean age 62 years , 39 male ) with various forms of recurrent progressive cancer participated , and 68 ( 88 % ) completed follow-up at 8 weeks . Patients completed  visual analogue scales assessing perceived ability to discuss end-of-life planning with healthcare professionals or family and friends  ( primary outcome ) , happiness with the level of communication , and satisfaction with care , as well as a st and ardized measure of anxiety and depression . RESULTS Thirty-eight patients ( 51 % ) showed preference for the intervention . Discussion s with professionals or family and friends about the future increased in the intervention arms , whether r and omized or preference , but happiness with communication was unchanged or worse , and satisfaction with services decreased . Trial participation did not cause significant anxiety or depression and attrition was low . SIGNIFICANCE OF RESULTS A r and omized trial of advance care planning is possible . This study provides new evidence on its acceptability and effectiveness for patients with advanced cancer PURPOSE Decision making regarding cardiopulmonary resuscitation ( CPR ) is challenging . This study examined the effect of a video decision support tool on CPR preferences among patients with advanced cancer . PATIENTS AND METHODS We performed a r and omized controlled trial of 150 patients with advanced cancer from four oncology centers . Participants in the control arm ( n = 80 ) listened to a verbal narrative describing CPR and the likelihood of successful resuscitation . Participants in the intervention arm ( n = 70 ) listened to the identical narrative and viewed a 3-minute video depicting a patient on a ventilator and CPR being performed on a simulated patient . The primary outcome was participants ' preference for or against CPR  measured immediately after exposure to either modality . Secondary outcomes were participants ' knowledge of CPR ( score range of 0 to 4 , with higher score indicating more knowledge ) and comfort with video . RESULTS The mean age of participants was 62 years ( st and ard deviation , 11 years ) ; 49 % were women , 44 % were African American or Latino , and 47 % had lung or colon cancer . After the verbal narrative , in the control arm , 38 participants ( 48 % ) wanted CPR , 41 ( 51 % ) wanted no CPR , and one ( 1 % ) was uncertain . In contrast , in the intervention arm , 14 participants ( 20 % ) wanted CPR , 55 ( 79 % ) wanted no CPR , and 1 ( 1 % ) was uncertain ( unadjusted odds ratio , 3.5 ; 95 % CI , 1.7 to 7.2 ; P < .001 ) . Mean knowledge scores were higher in the intervention arm than in the control arm ( 3.3 ± 1.0 v 2.6 ± 1.3 , respectively ; P < .001 ) , and 65 participants ( 93 % ) in the intervention arm were comfortable watching the video . CONCLUSION Participants with advanced cancer who viewed a video of CPR were less likely to opt for CPR than those who listened to a verbal narrative Background The Medical Research Councils ’ framework for complex interventions has been criticized for not including theory-driven approaches to evaluation . Although the framework does include broad guidance on the use of theory , it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach . A prospect i ve , theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective , sustainable and scalable . Methods We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool , Theory of Change ( ToC ) , into the MRC framework for complex interventions . We provide a guide to what ToC is , how to construct one , and how to integrate its use into research projects seeking to design , implement and evaluate complex interventions using the MRC framework . We test this approach by using ToC within two r and omized controlled trials and one non-r and omized evaluation of complex interventions . Results Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework . It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly design ing an intervention that is embedded in the local context . For the feasibility and piloting stage , ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design . ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all stages of the causal pathway through which an intervention achieves impact , combining evaluations of intervention effectiveness with detailed process evaluations into one theoretical framework . Conclusions Incorporating a ToC approach into the MRC framework holds promise for improving the design and evaluation of complex interventions , thereby increasing the likelihood that the intervention will be ultimately effective , sustainable and scalable . We urge research ers developing and evaluating complex interventions to consider using this approach , to evaluate its usefulness and to build an evidence base to further refine the methodology .Trial registration Clinical trials.gov : PURPOSE To determine whether the use of a goals -of-care video to supplement a verbal description can improve end-of-life decision making for patients with cancer . METHODS Fifty participants with malignant glioma were r and omly assigned to either a verbal narrative of goals -of-care options at the end of life ( control ) , or a video after the same verbal narrative ( intervention ) in this r and omized controlled trial . The video depicts three levels of medical care : life-prolonging care ( cardiopulmonary resuscitation [ CPR ] , ventilation ) , basic care ( hospitalization , no CPR ) , and comfort care ( symptom relief ) . The primary study outcome was participants ' preferences for end-of-life care . The secondary outcome was participants ' uncertainty regarding decision making ( score range , 3 to 15 ; higher score indicating less uncertainty ) . Participants ' comfort level with the video was also measured . RESULTS Fifty participants were r and omly assigned to either the verbal narrative ( n = 27 ) or video ( n = 23 ) . After the verbal description , 25.9 % of participants preferred life-prolonging care , 51.9 % basic care , and 22.2 % comfort care . In the video arm , no participants preferred life-prolonging care , 4.4 % preferred basic care , 91.3 % preferred comfort care , and 4.4 % were uncertain ( P < .0001 ) . The mean uncertainty score was higher in the video group than in the verbal group ( 13.7 v 11.5 , respectively ; P < .002 ) . In the intervention arm , 82.6 % of participants reported being very comfortable watching the video . CONCLUSION Compared with participants who only heard a verbal description , participants who viewed a goals -of-care video were more likely to prefer comfort care and avoid CPR , and were more certain of their end-of-life decision making . Participants reported feeling comfortable watching the video 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 BACKGROUND  Cardiopulmonary resuscitation ( CPR ) is an important advance directive ( AD ) topic in patients with progressive cancer ; however such discussion s are challenging . OBJECTIVE This study investigates whether video educational information about CPR engenders broader advance care planning ( ACP ) discourse . METHODS Patients with progressive pancreas or hepatobiliary cancer were r and omized to an educational CPR video or a similar CPR narrative . The primary end-point was the difference in ACP documentation one month posttest between arms . Secondary end-points included study impressions ; pre- and post-intervention knowledge of and preferences for CPR and mechanical ventilation ; and longitudinal patient outcomes . RESULTS Fifty-six subjects were consented and analyzed . Rates of ACP documentation ( either formal ADs or documented discussion s ) were 40 % in the video arm ( 12/30 ) compared to 15 % in the narrative arm ( 4/26 ) , OR=3.6 [ 95 % CI : 0.9 - 18.0 ] , p=0.07 . Post-intervention knowledge was higher in both arms . Posttest , preferences for CPR had changed in the video arm but not in the narrative arm . Preferences regarding mechanical ventilation did not change in either arm . The majority of subjects in both arms reported the information as helpful and comfortable to discuss , and they recommended it to others . More deaths occurred in the video arm compared to the narrative arm , and more subjects died in hospice setting s in the video arm . CONCLUSIONS This pilot r and omized trial addressing downstream ACP effects of video versus narrative decision tools demonstrated a trend towards more ACP documentation in video subjects . This trend , as well as other video effects , is the subject of ongoing study BACKGROUND Advance Care Planning ( ACP ) is a systematic approach to ensure that effective advance directives ( ADs ) are developed and respected . We studied the effects of implementing a regional ACP program in Germany . METHODS In a prospect i ve , inter-regionally controlled trial focusing on nursing homes ( n/hs ) , we compared the number , relevance and validity of new ADs completed in the intervention region versus the control region .  Intervention n/h residents and their families were offered professional facilitation including st and ardized documentation . RESULTS Data from 136 residents of three intervention n/hs were compared with data from 439 residents of 10 control n/hs over a study period of 16.5 months . In the intervention region , 49 ( 36.0 % ) participating residents completed a new AD over the period of the study , compared to 18 ( 4.1 % ) in the control region ; these ADs included 30 ADs by proxy in the intervention region versus 10 in the control region . Proxies were design ated in 94.7 % versus 50.0 % of cases , the AD was signed by a physician in 93.9 % versus 16.7 % , and an emergency order was included in 98.0 % versus 44.4 % . Resuscitation status was addressed in 95.9 % versus 38.9 % of cases ( p<0.01 for all of the differences mentioned above ) . In the intervention region , new ADs were preceded by an average of 2.5 facilitated conversations ( range , 2–5 ) with a mean total duration of 100 minutes ( range , 60–240 minutes ) . CONCLUSION The implementation of an ACP program in German nursing homes led , much more frequently than previously reported , to the creation of advance directives with potential relevance to medical decision-making . Future research should assess the effect of such programs on clinical and structural outcomes Purpose To build on results of a cluster r and omized controlled trial ( RCT ) of a combined patient-oncologist intervention to improve communication in advanced cancer , we conducted a post hoc analysis of the patient intervention component , a previsit patient coaching session that used a question prompt list ( QPL ) . We hypothesized that intervention-group participants would bring up more QPL-related topics , particularly prognosis-related topics , during the subsequent oncologist visit . Patients and Methods This cluster RCT with 170 patients who had advanced nonhematologic cancer ( and their caregivers ) recruited from practice s of 24 participating oncologists in western New York . Intervention-group oncologists ( n = 12 ) received individualized communication training ; up to 10 of their patients ( n = 84 ) received a previsit individualized communication coaching session that incorporated a QPL . Control-group oncologists ( n = 12 ) and patients ( n = 86 ) received no interventions . Topics of interest identified by patients during the coaching session were summarized from coaching notes ; one office visit after the coaching session was audio recorded , transcribed , and analyzed by using linear regression modeling for group differences . Results Compared with controls , more than twice as many intervention-group participants brought up QPL-related topics during their office visits ( 70.2 % v 32 
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Conclusion : The use of conceptual models underpinning the development of advance care planning is uncommon .
When used , they identify the individual behavioural change .
Strengthening patients ’ motivation and competence in participating advance care planning discussion s are key mechanisms of change .