Preparing Surrogates of Dementia Patients Through an Advance Care Planning Intervention

Modified Family Member Decision-Making Self-efficacy Scale (FDMSE) - Chinese version,Family Distress in Advanced Dementia Scale (FDAD) - Chinese version

The goal of this clinical trial is to evaluate the effects of a nurse-facilitated
 post-discharge advance care planning intervention with family surrogates of dementia patients
 on outcomes that reflect the preparedness of surrogates in decision-making.
 
 The main question it aims to answer is, whether the ACP intervention as compared with usual
 care will increase family surrogates' self-efficacy in surrogate decision-making and reduce
 their levels of distress, and increase patient comfort and reduce acute healthcare
 utilization at 2 and 6 months.
 
 Participants will be randomized to ACP intervention vs. usual care.
 
 1. patients of the Intervention group will be assessed on palliative care needs, and
 surrogates of the Intervention group will participate in 2-3 nurse-led ACP
 consultations;
 
 2. surrogates of both intervention and control groups will complete 3 surveys at different
 time points during their participation of the study.
 
 Researchers will compare the intervention group and control group to see any differences in:
 
 1. surrogate preparedness for decision-making,
 
 2. distress of surrogate and satisfaction with the care of loved one with dementia at the
 end-of-life,
 
 3. enrolment in Community Geriatric Assessment Team end-of-life care program,
 
 4. advanced care program documentation in medical record,
 
 5. patient comfort at end-of-life,
 
 6. hospitalizations in the last 6 months of life.