Development of A Terminal Patient Assessment Instrument Based on Advance Care Planning: A Systematic Review
Keywords:
advance care planning, assessment instrument, intensive care unit, palliative care, terminal patientAbstract
Terminally ill patients in the Intensive Care Unit (ICU) require a comprehensive assessment to support clinical decision-making and individualized care. However, existing assessment instruments do not fully integrate Advance Care Planning (ACP). This systematic review aimed to identify the key components of terminal patient assessment instruments incorporating ACP. A systematic review was conducted following the PRISMA guidelines. Electronic databases were searched using keywords related to terminal patients, assessment instruments, ACP, and ICU. Eligible studies were analyzed using narrative synthesis. The review identified key assessment domains, including neurological status, physical symptoms, functional performance, psychosocial condition, spiritual needs, communication with patients and families, and goals of care. Most instruments did not comprehensively integrate ACP components, resulting in variations in assessment and documentation practices. Integrating ACP into terminal patient assessment instruments may improve identification of patient needs, documentation quality, and nursing decision-making in the ICU.
References
Abera, E. G., Himbaro, S. A., & Gizaw, H. S. (2026). Barriers to and readiness for advance care planning : a systematic review and meta- analysis of quantitative and qualitative evidence.
Ashana, D. C., Ms, M. B. A., Pratt, E. H., Haines, K., & Carolina, N. (2024). family members : intensive care unit prospective cohort study ”.
Bijnsdorp, F. M., Schouten, B., Reyners, A. K. L., Wagner, C., Francke, A. L., & van Schoten, S. M. (2023). Measurement and documentation of quality indicators for the end-of-life care of hospital patients a nationwide retrospective record review study. BMC Palliative Care, 22(1), 1–12. https://doi.org/10.1186/s12904-023-01299-x
Choudhuri, A. H., Sharma, A., & Uppal, R. (2020). Effects of delayed initiation of end-of-life care in terminally Ill intensive care unit patients. Indian Journal of Critical Care Medicine, 24(6), 404–408. https://doi.org/10.5005/jp-journals-10071-23454
Gray, N. A., Kamal, A. H., Hanson, L. C., Bull, J., Kutner, J. S., Ritchie, C. S., Johnson, K. S., & Al, G. E. T. (2022). Clinician Perspectives Guiding Approach to Comprehensiveness of Palliative Care Assessment 1. 25(2). https://doi.org/10.1089/jpm.2021.0391
Hoffmann, F., Schnakenberg, R., Silies, K., Berg, A., Kirchner, Ä., Jaschke, J., Haastert, B., Wiese, B., Köberlein-neu, J., Meyer, G., & Köpke, S. (2023). Effects of advance care planning in care dependent community-dwelling older persons ( STADPLAN ): A cluster-randomised controlled trial. https://doi.org/10.1177/02692163231180322
Huriani, E., Susanti, M., & Sari, R. D. (2022). Pengetahuan dan kepercayaan diri tentang perawatan paliatif pada perawat icu 1,3. 7(1), 74–84.
Jaschke, J., Schnakenberg, R., Silies, K., Berg, A., Kirchner, Ä., & Hoffmann, F. (2024). Measuring patients ’ medical treatment preferences in advance care planning : development and validation of the Treat-Me- ACP instrument – a secondary analysis of a cluster-randomized controlled trial. 1–11.
Jeong, S., Cleasby, P., Ohr, S. O., Barrett, T., Davey, R., & Oldmeadow, C. (2021). Efficacy of Normalisation of Advance Care Planning ( NACP ) for people with chronic diseases in hospital and community settings : a quasi-experimental study. 1–12.
Kemenkes RI. (2023). Keputusan Menteri Kesehatan Republik Indonesia. Keputusan Menteri Kesehatan Republik Indonesia Tentang Pedoman Penyelenggaraan Pelayanan Paliatif, 4(1), 1–23. https://ejournal.poltektegal.ac.id/index.php/siklus/article/view/298%0Ahttp://repositorio.unan.edu.ni/2986/1/5624.pdf%0Ahttp://dx.doi.org/10.1016/j.jana.2015.10.005%0Ahttp://www.biomedcentral.com/1471-2458/12/58%0Ahttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&P
Lo, M. L., Huang, C. C., Hu, T. H., Chou, W. C., Chuang, L. P., Chiang, M. C., Wen, F. H., & Tang, S. T. (2020). Quality Assessments of End-of-Life Care by Medical Record Review for Patients Dying in Intensive Care Units in Taiwan. Journal of Pain and Symptom Management, 60(6), 1092-1099.e1. https://doi.org/10.1016/j.jpainsymman.2020.07.002
Mardevian, D., Yusuf, M., Jannah, N., Mayasari, P., Kuala, U. S., Kuala, U. S., & Kuala, U. S. (2025). Evaluasi Kelengkapan Dokumentasi Catatan Perkembangan Pasien Terintegrasi ( CPPT ) Keperawatan. 5(3), 561–570.
Maulana, I., Ns, M. B., Amanupunnyo, N. A., & Hasan, S. M. (2024). Konsep Perawatan Pasien Paliatif. Media Pustaka Indo.
Mcmahan, R. D., Hickman, S. E., & Sudore, R. L. (2023). What Clinicians and Researchers Should Know About the Evolving Field of Advance Care Planning : a Narrative Review. Journal of General Internal Medicine, (0123456789), 652–660. https://doi.org/10.1007/s11606-023-08579-5
Mulyatsih, M., Rohani, S., Suyani, A., Aisyiyah, U., & Komariah, S. (2021). Persepsi Perawat tentang Pelayanan Pasien Tahap Terminal. Journal of Hospital Accreditation, 03(1), 39–45.
Permenkes. (2010). Keputusan menteri kesehatan republik indonesia nomor 1778/menkes/sk/xii/2010 tentang pedoman penyelenggaraan pelayanan.
Ruhmadi, E., & Santosa, H. A. B. (2022). Studi Komparatif Quality of Life Pada Pasien Terminal Illness. 9(1), 17–23.
Sjöberg, M., Edberg, A. K., Rasmussen, B. H., & Beck, I. (2021). Documentation of older people’s end-of-life care in the context of specialised palliative care: a retrospective review of patient records. BMC Palliative Care, 20(1), 1–12. https://doi.org/10.1186/s12904-021-00771-w
Spadaro, S., Azzolina, D., Vuan, A., Colasanto, L., Manzetto, C., Busnardo, A., Filieri, G., Fagogeni, P., Ganzaroli, F., Gamanji, V., Poles, G., Spinazzola, G., Volta, C. A., Scaramuzzo, G., & Gulmini, L. (2025). Early Detection of Palliative Care Needs in Critically Ill Patients Using the NECPAL Tool. 1–12.
Tashkandi et al, Tashkandi, D. K., Bokhari, W. A., A. Justaniah, N., Alshehri, W. S., Almalky, N. A., Hemeq, Y. H., Anwar Khan, M., & Tashkandi et al. (2024). The Predictive Role of Modified Early Warning Score and Palliative Performance Scale in Imminent Death Diagnosis in a Palliative Care Setting Among Adult Advanced Cancer Patients: A Retrospective Cohort Study. Journal of Healthcare Sciences, 04(12), 884–897. https://doi.org/10.52533/johs.2024.41231
Yamamoto, K., Yonekura, Y., & Nakayama, K. (2022). Healthcare providers ’ perception of advance care planning for patients with critical illnesses in acute-care hospitals : a cross-sectional study. BMC Palliative Care, 1–12. https://doi.org/10.1186/s12904-021-00900-5
Yen, Y.-F., Lee, L., Hu, Y., & Ko, M.-C. (2022). Early palliative care : the surprise question and the palliative care screening tool — better together. 211–217. https://doi.org/10.1136/bmjspcare-2019-002116
Yeo, N. Y., Deane, A. M., Kentish-barnes, N., Saxena, M., Uk, F., Aus, F., Williams, P. J., Moran, J. L., Reddi, B. A. J., & Uk, F. (2026). Australian Critical Care Goals of care and palliative care practices in critically ill patients : A multicentre , binational , point prevalence study. Australian Critical Care, 39(3), 101582. https://doi.org/10.1016/j.aucc.2026.101582
Zhang, C., Barrios, M., & Guilera, G. (2026). International Journal of Nursing Studies Advances Measurement instruments in advance care planning. 10(March). https://doi.org/10.1016/j.ijnsa.2026.100518
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Erwin Aprilia Puji Lestari, Ah Yusuf, Ika Nur Pratiwi, Daniel Nong Danche
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
