Is This ACP? A Focus Group Study of Patient Experiences of Advance Care Planning

Factors influencing advance care planning among cancer patients: A qualitative study

PURPOSE

The study aims to explore the factors influencing advance care planning among cancer patients, recognizing the importance of understanding these factors to enhance patient outcomes and ensure that patients' preferences are honored.

METHODS

Conducted from May to November 2023, this qualitative descriptive study employed a phenomenological research approach. In-depth face-to-face interviews and observations were utilized to gather insights into the factors influencing participation in advance care planning, guided by a semi-structured interview outline based on social ecosystem theory. Content analysis and thematic analysis were applied to identify and interpret key themes from the data.

RESULTS

A total of 17 cancer patients participated in the interviews. The analysis revealed four main themes. Facilitating factors included optimistic health views and positive attitudes toward advance care planning, which encouraged engagement. Conversely, barriers such as a lack of understanding of advance care planning, misconceptions, and negative attitudes hindered participation. Family dynamics played a significant role; trust in family decisions facilitated discussions, while family pressure created challenges. Economic burdens and cultural taboos surrounding death, along with reliance on healthcare providers, impeded open conversations. These findings highlight the necessity for targeted strategies to enhance patient involvement in advance care planning.

CONCLUSION

Cancer patients' advance care planning is influenced by positive factors like optimistic health views and supportive family dynamics, as well as obstacles such as misconceptions, cultural taboos, and economic burdens. Targeted interventions are needed to empower patients and better align care with their values.

Coming to terms with dying: Advance care planning as a conduit between clinicians, patients, and conversations about death and dying - a qualitative interview study

BACKGROUND

Advance care planning discussions exploring future care and support needs can be beneficial to people with advanced illness. While research has focussed on barriers, outcomes, and completion, little is known about how discussions influence thoughts, feelings, and behaviours.

AIM

To explore experiences of advance care planning for people with incurable life-limiting illnesses, to understand the impact of discussions on individuals, and factors influencing psychological responses.

DESIGN

Semi-structured qualitative interviews were conducted. Data were analysed using framework analysis. Reflexive journalling and discussion of coding framework and themes supported rigour.

SETTING/PARTICIPANTS

Twenty purposively sampled adults receiving hospice care, aged 30-93 with cancer (n = 15) and non-cancer (n = 5) diagnoses were interviewed.

RESULTS

Advance care planning elicits multiple complex thoughts, emotions, and behaviours, with responses ranging from the procedural to the profound. Discussions empowered and instilled confidence, promoted openness with relatives, encouraged people to make the most of their time remaining, and sometimes contributed to coming to terms with their mortality. Factors influencing experiences of discussions reflected the complexity and diversity in participants' lives, personalities, and life experiences, with discussions exposing the realities of living with terminal illness.

CONCLUSION

Individuals' unique lives and experiences shape their responses to, and the impact of advance care planning on how they think, feel and behave. Advance care planning is not simply a means to document end-of-life care preferences, but can empower and instil confidence in patients, and may form part of the process of coming to terms with mortality, allowing clinicians to shift focus from process-related outcomes.

Community-dwelling older people's experiences of advance care planning with health care professionals: a qualitative systematic review

OBJECTIVE

The objective of this review was to examine community-dwelling older people's experiences of advance care planning with health care professionals.

INTRODUCTION

The importance of health care professionals initiating advance care planning for patients has been reported; however, because of the shift from institutionalized to community care, community-dwelling older people have fewer opportunities to discuss these plans with health care professionals compared with older people living in other settings. The timely initiation of advance care planning and sustainable discussions among older people, their families, and community health care professionals is necessary and may improve palliative and end-of-life care.

INCLUSION CRITERIA

Studies with participants aged 60 years and older who have experience with advance care planning and live in their own homes in the community were included. We considered qualitative studies and the qualitative component of mixed methods studies published between January 1999 and April 2023 in English or Japanese.

METHODS

MEDLINE (EBSCOhost), CINAHL (EBSCOhost), Embase, PsycINFO (EBSCOhost), JSTOR, Scopus, Japan Medical Abstract Society, and CiNii were searched for published papers. Google Scholar, ProQuest Dissertations and Theses Global and MedNar were searched for unpublished papers and gray literature. Study selection, critical appraisal, data extraction, and data synthesis were conducted by 2 independent reviewers using the JBI approach and JBI standardized tools. Findings were pooled using a meta-aggregation approach. The synthesized findings were graded using the ConQual approach for establishing confidence in the output of qualitative research syntheses and presented in a Summary of Findings.

RESULTS

Five studies published between 2017 and 2022 were included in the review. Each study scored between 6 and 8 out of 10 on the JBI critical appraisal checklist for qualitative research. We extracted 28 findings and aggregated them into 7 categories, generating 3 synthesized findings: i) A trusting relationship with health care professionals is essential for older people's decision-making. Health care professionals' attitudes, knowledge, and skills play a role in this, influencing the perceived quality of care; ii) Shared decision-making and patient-centered communication are essential. Older people feel ambiguity toward end-of-life decision and advance care planning, and they want their wishes to be heard in any situation to maintain their autonomy and quality of life; iii) Older people need the appropriate forms and accessible and coordinated care to begin advance care planning.

CONCLUSION

Qualitative studies on community-dwelling older people's experiences of advance care planning with health care professionals are scarce. The experiences have illustrated that trusting relationships influence people's perception of the quality of care they receive; there is uncertainty about their future; and they have varying feelings or attitudes toward their impending death, including denial and avoidance. This review highlights the need for appropriate forms, and accessible and coordinated care to begin advance care planning; thus, an approach that meets the individual's health and psychosocial status should be selected carefully. Further research is recommended to include older populations from broader geographical and cultural backgrounds, and to assess and evaluate the different advance care planning approaches and their implementation processes among groups of community-dwelling older people with different health and psychosocial statuses.

REVIEW REGISTRATION

PROSPERO CRD42020122803.

Qualitative evaluation of the SHARING Choices trial of primary care advance care planning for adults with and without dementia

BACKGROUND

Primary care can be an important setting for communication and advance care planning (ACP), including for those with dementia and their families. The study objective was to explore experiences with a pragmatic trial of a communication and ACP intervention, SHARING Choices, in primary care for older adults with and without dementia.

METHODS

We conducted qualitative interviews using tailored semi-structured guides with three groups: ACP facilitators who conducted the intervention; clinicians, managers, and administrators from sites randomized to the intervention; and patients and families who met with ACP facilitators. We used thematic analysis to identify and synthesize emergent themes based on key Consolidated Framework for Implementation Research concepts and Proctor's Implementation Outcomes, triangulating the three groups' perspectives.

RESULTS

We identified five key themes. For acceptability, perceptions of the intervention were mostly positive, although some components were not generally implemented. For adoption, respondents perceived that ACP facilitators mainly focused on conducting ACP, although facilitators often did not implement the ADRD and family engagement aspects with the ACP. For relational connections, ACP facilitator-practice and clinician communication and engagement were key to how the intervention was implemented. For adaptability, ACP facilitators and health systems adapted how the ACP facilitation component was implemented to local preferences and over time, given the pragmatic nature of the trial. And, for sustainability, ACP facilitators and clinicians/managers/facilitators were positive that the intervention should be continued but noted barriers to its sustainability. Patients and families generally did not recall the intervention.

CONCLUSIONS

ACP facilitators and clinicians, managers, and administrators had positive perceptions of the ACP facilitator component of the intervention in this pragmatic trial with adaptation to local preferences. However, engaging those with dementia and families was more challenging in the implementation of this intervention.

Using the Recommended Summary Plan for Emergency Care and Treatment in Primary Care: a mixed methods study

Background

Emergency care treatment plans provide recommendations about treatment, including cardiopulmonary resuscitation, to be considered in emergency medical situations. In 2016, the Resuscitation Council United Kingdom developed a standardised emergency care treatment plan, the recommended summary plan for emergency care and treatment, known as ReSPECT. There are advantages and potential difficulties in initiating the ReSPECT process in primary care. Hospital doctors and general practitioners may use the process differently and recommendations do not always translate between settings. There are no large studies of the use of ReSPECT in the community.

Study aim

To evaluate how, when and why ReSPECT is used in primary care and what effect it has on patient treatment and care.

Design

A mixed-methods approach using interviews, focus groups, surveys and evaluation of ReSPECT forms within an analytical framework of normalisation process theory.

Setting

A total of 13 general practices and 13 care homes across 3 areas of England.

Participants

General practitioners, senior primary care nurses, senior care home staff, patients and their relatives, community and emergency department clinicians and home care workers, people with learning disability and their carers. National surveys of (1) the public and (2) general practitioners.

Results

Members of the public are supportive of emergency care treatment plans. Respondents recognised benefits of plans but also potential risks if the recommendations become out of date. The ReSPECT plans were used by 345/842 (41%) of general practitioner survey respondents. Those who used ReSPECT were more likely to be comfortable having emergency care treatment conversations than respondents who used standalone 'do not attempt cardiopulmonary resuscitation' forms. The recommended summary plan for emergency care and treatment was conceptualised by all participants as person centred, enabling patients to have some say over future treatment decisions. Including families in the discussion is seen as important so they know the patient's wishes, which facilitates decision-making in an emergency. Writing recommendations is challenging because of uncertainty around future clinical events and treatment options. Care home staff described conflict over treatment decisions with clinicians attending in an emergency, with treatment decisions not always reflecting recommendations. People with a ReSPECT plan and their relatives trusted that recommendations would be followed in an emergency, but carers of people with a learning disability had less confidence that this would be the case. The ReSPECT form evaluation showed 87% (122/141) recorded free-text treatment recommendations other than cardiopulmonary resuscitation. Patient preferences were recorded in 57% (81/141). Where a patient lacked capacity the presence of a relative or lasting power of attorney was recorded in two-thirds of forms.

Limitations

Recruitment for patient/relative interviews was less than anticipated so caution is required in interpreting these data. Minority ethnic groups were under-represented across our studies.

Conclusions

The aims of ReSPECT are supported by health and social care professionals, patients, and the public. Uncertainty around illness trajectory and treatment options for a patient in a community setting cannot be easily translated into specific recommendations. This can lead to conflict and variation in how recommendations are interpreted.

Future work

Future research should explore how best to integrate patient values into treatment decision-making in an emergency.

Study registration

This study is registered as NCT05046197.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131316) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 42. See the NIHR Funding and Awards website for further award information.

Barriers to advance care planning among patients with advanced serious illnesses: A national survey of health-care professionals in Singapore

OBJECTIVES

To assess the barriers that health-care professionals (HCPs) face in having advance care planning (ACP) conversations with patients suffering from advanced serious illnesses and to provide care consistent with patients' documented preferences.

METHODS

We conducted a national survey of HCPs trained in facilitating ACP conversations in Singapore between June and July 2021. HCPs responded to hypothetical vignettes about a patient with an advanced serious illness and rated the importance of barriers (HCP-, patient-, and caregiver-related) in (i) conducting and documenting ACP conversations and (ii) providing care consistent with documented preferences.

RESULTS

Nine hundred eleven HCPs trained in facilitating ACP conversations responded to the survey; 57% of them had not facilitated any in the last 1 year. HCP factors were reported as the topmost barriers to facilitating ACP. These included lack of allocated time to have ACP conversations and ACP facilitation being time-consuming. Patient's refusal to engage in ACP conversations and family experiencing difficulty in accepting patient's poor prognosis were the topmost patient- and caregiver-related factors. Non-physician HCPs were more likely than physicians to report being fearful of upsetting the patient/family and lack of confidence in facilitating ACP conversations. About 70% of the physicians perceived caregiver factors (surrogate wanting a different course of treatment and family caregivers being conflicted about patients' care) as barriers to providing care consistent with preferences.

SIGNIFICANCE OF RESULTS

Study findings suggest that ACP conversations be simplified, ACP training framework be improved, awareness regarding ACP among patients, caregivers, and general public be increased, and ACP be made widely accessible.

Barriers and Strategies to Effective Serious Illness Communication for Patients with End-Stage Liver Disease in the Intensive Care Setting

Background: Patients with end-stage liver disease (ESLD) often require Intensive Care Unit (ICU) admission during the disease trajectory, but aggressive medical treatment has not resulted in increased quality of life for patients or caregivers. Methods: This narrative review synthesizes relevant data thematically exploring the current state of serious illness communication in the ICU with identification of barriers and potential strategies to improve performance. We provide a conceptual model underscoring the importance of providing comprehensible disease and prognosis knowledge, eliciting patient values and aligning these values with available goals of care options through a series of discussions. Achieving effective serious illness communication supports the delivery of goal concordant care (care aligned with the patient's stated values) and improved quality of life. Results: General barriers to effective serious illness communication include lack of outpatient serious illness communication discussions; formalized provider training, literacy and culturally appropriate patient-directed serious illness communication tools; and unoptimized electronic health records. ESLD-specific barriers to effective serious illness communication include stigma, discussing the uncertainty of prognosis and provider discomfort with serious illness communication. Evidence-based strategies to address general barriers include using the Ask-Tell-Ask communication framework; clinician training to discuss patients' goals and expectations; PREPARE for Your Care literacy and culturally appropriate written and online tools for patients, caregivers, and clinicians; and standardization of documentation in the electronic health record. Evidence-based strategies to address ESLD-specific barriers include practicing with empathy; using the "Best-Case, Worst Case" prognostic framework; and developing interdisciplinary solutions in the ICU. Conclusion: Improving clinician training, providing patients and caregivers easy-to-understand communication tools, standardizing EHR documentation, and improving interdisciplinary communication, including palliative care, may increase goal concordant care and quality of life for critically ill patients with ESLD.

Patient and relative experiences of the ReSPECT process in the community: an interview-based study

BACKGROUND

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) was launched in the UK in 2016. ReSPECT is designed to facilitate meaningful discussions between healthcare professionals, patients, and their relatives about preferences for treatment in future emergencies; however, no study has investigated patients' and relatives' experiences of ReSPECT in the community.

OBJECTIVES

To explore how patients and relatives in community settings experience the ReSPECT process and engage with the completed form.

METHODS

Patients who had a ReSPECT form were identified through general practice surgeries in three areas in England; either patients or their relatives (where patients lacked capacity) were recruited. Semi-structured interviews were conducted, focusing on the participants' understandings and experiences of the ReSPECT process and form. Data were analysed using inductive thematic analysis.

RESULTS

Thirteen interviews took place (six with patients, four with relatives, three with patient and relative pairs). Four themes were developed: (1) ReSPECT records a patient's wishes, but is entangled in wider relationships; (2) healthcare professionals' framings of ReSPECT influence patients' and relatives' experiences; (3) patients and relatives perceive ReSPECT as a do-not-resuscitate or end-of-life form; (4) patients' and relatives' relationships with the ReSPECT form as a material object vary widely. Patients valued the opportunity to express their wishes and conceptualised ReSPECT as a process of caring for themselves and for their family members' emotional wellbeing. Participants who described their ReSPECT experiences positively said healthcare professionals clearly explained the ReSPECT process and form, allocated sufficient time for an open discussion of patients' preferences, and provided empathetic explanations of treatment recommendations. In cases where participants said healthcare professionals did not provide clear explanations or did not engage them in a conversation, experiences ranged from confusion about the form and how it would be used to lingering feelings of worry, upset, or being burdened with responsibility.

CONCLUSIONS

When ReSPECT conversations involved an open discussion of patients' preferences, clear information about the ReSPECT process, and empathetic explanations of treatment recommendations, working with a healthcare professional to co-develop a record of treatment preferences and recommendations could be an empowering experience, providing patients and relatives with peace of mind.

The PACT Project: Feasibility of a Multidisciplinary, Multi-Faceted Intervention to Promote Goals of Care Conversations

BACKGROUND

Patients living with serious illness generally want their physicians to facilitate Goals of Care conversations (GoCc), yet physicians may lack time and skills to engage in these conversations in the outpatient setting. The problem may be addressed by supporting multiple members of the clinical team to facilitate GoCc with the patient while admitted to the hospital.

METHODS

A multi-modal training and mentored implementation program was developed. A group of 10 hospitals were recruited to participate. Each hospital selected a primary inpatient unit on which to start the intervention, then expanded to a secondary unit later in the project. The number of trained facilitators (champions) and the number of documented GoCc were tracked over time.

RESULTS

Nine of 10 hospitals completed the 3-year project. Most of the units were general medical-surgical units. Forty-eight champions were trained at the kick-off conference, attended primarily by nurses, physicians, and social workers. By the end of the project, 153 champions had been trained. A total of 51 087 patients were admitted to PACT units with 85.4% being screened for eligibility. Of the patients who were eligible, over 68% had documented GoCc.

CONCLUSION

A multifaceted quality improvement intervention focused on serious illness communication skills can support a diverse clinical workforce to facilitate inpatient GoCc over time.

Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study

RATIONALE & OBJECTIVE

Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population.

STUDY DESIGN

National explanatory sequential mixed methods study including an online survey and semistructured interviews.

SETTING & PARTICIPANTS

Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022.

ANALYTICAL APPROACH

Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data.

RESULTS

A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care.

LIMITATIONS

Potential selection bias.

CONCLUSIONS

Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them.

PLAIN-LANGUAGE SUMMARY

Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.

Advance Care Planning, Shared Decision Making, and Serious Illness Conversations in Onconephrology

Advance care planning, shared decision making, and serious illness conversations are communication processes designed to promote patient-centered care. In onconephrology, patients face a series of complex medical decisions regarding their care at the intersection of oncology and nephrology. Clinicians who aim to ensure that patient preferences and values are integrated into treatment planning must work within a similarly complex care team comprising multiple disciplines. In this review, we describe key decision points in a patient's care trajectory, as well as guidance on how and when to engage in advance care planning, shared decision making, and serious illness discussions. Further research on these processes in the complex context of onconephrology is needed.

Educational Resources and Self-Management Support to Engage Patients in Advance Care Planning: An Interpretation of Current Practice in the US

BACKGROUND

Educational resources and decision aids help patients, their care partners and health care providers prepare for and confidently engage in Advance Care Planning (ACP). Incorporating ACP resources as part of a self-management approach may lead to fuller engagement with ACP beyond identifying a surrogate decision-maker, towards supporting a person to identify their values and goals and to communicate them with their care partners and health care providers.

OBJECTIVE

To examine the use of educational resources and decision aids to support self-management of ACP in 11 health systems across the US.

METHODS

This study was a qualitative interview study examining barriers and facilitators to ACP. Guided by interpretative description and the chronic care model, we sought to describe how health care stakeholders (clinicians and administrators) and patients use ACP resources to support engagement with ACP.

RESULTS

274 health care stakeholders were interviewed, and 7 patient focus groups were conducted across 11 health systems. The majority of participants reported using resources to support completion of preference documentation, with fewer participants using resources that promote more engagement in ACP. ACP resources were reported as valuable in preparing for and complementing a complex, interpersonal, and interprofessional process. Barriers to using resources included a lack of a defined workflow and time.

CONCLUSION

Our data suggest that ACP resources that promote engagement are valued but under-utilized in practice. The use of ACP resources with an inter-professional team and a self-management approach is a promising strategy to mitigate the barriers of ACP implementation while improving engagement in ACP.