title: Advance care planning in people with early cognitive impairment.
abstract: OBJECTIVE
  People with early cognitive impairment (ECI), comprising mild cognitive impairment and early dementia face the risk of diminished mental capacity with progressive disease. Advance care planning (ACP) is advocated as a means to uphold the autonomy of individuals and enable them to express their wishes for the future while they still possess mental capacity. This study aims to explore the perspectives of patients with ECI regarding ACP, and in particular, understand their reasons for resistance.
  
  
  METHODS
  Consecutive patients undergoing a counselling service for persons with ECI who fulfilled inclusion criteria (Mini Mental State Examination score ≥18, Global Clinical Dementia Rating (GCDR)=0.5 or 1 were recruited. Demographic and clinical data was collected and the detailed documentation in the case records of the counselling sessions was subjected to a thematic analysis. Differences between patients who were willing to engage in ACP and those who declined were also analysed.
  
  
  RESULTS
  93 patients (mean age 76, 60.2% female) were recruited of which 38.7% chose to engage further in ACP discussions. GCDR was the only factor that emerged significant on bivariate analysis for willingness to engage in ACP (t (79)=2.191, p<0.05, two-tailed) whereby milder CI was associated with a greater likelihood of ACP engagement. Among those who declined ACP, three main themes emerged from the thematic analysis. The majority deferred decision-making to their families. Some perceived ACP as irrelevant or unnecessary, and displayed avoidance and denial during ACP discussions.
  
  
  CONCLUSIONS
  A large proportion of patients with ECI decline ACP discussions and the reasons are influenced by personal values, coping behaviours and sociocultural norms. These findings have important implications for practice.
authors.affiliation: James Cook University, Singapore.
authors.forename: Kenny
authors.initials: K
authors.lastname: Cheong
authors.affiliation: James Cook University, Singapore Department of Clinical Psychology, Norwich Medical School, University of East Anglia, UK.
authors.forename: Paul
authors.initials: P
authors.lastname: Fisher
authors.affiliation: Department of Medical Social Service, Khoo Teck Puat Hospital, Singapore.
authors.forename: Jenny
authors.initials: J
authors.lastname: Goh
authors.affiliation: Department of Medical Social Service, Khoo Teck Puat Hospital, Singapore.
authors.forename: Lynette
authors.initials: L
authors.lastname: Ng
authors.affiliation: Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore.
authors.forename: Hui Mien
authors.initials: HM
authors.lastname: Koh
authors.affiliation: Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore.
authors.forename: Philip
authors.initials: P
authors.lastname: Yap
mesh_terms: D000223:Adaptation, Psychological; D032722:Advance Care Planning / Q000706:statistics & numerical data*; D000368:Aged; D001362:Avoidance Learning; D003072:Cognition Disorders / Q000523:psychology*; D003657:Decision Making; D003717:Denial, Psychological; D042241:Early Diagnosis; D005190:Family; D005260:Female; D006801:Humans; D008297:Male; D011569:Psychiatric Status Rating Scales
keywords: Advance care planning; Alzheimer's disease; Dementia; Early cognitive impairment; Mild cognitive impairment