Barriers and facilitators to implementing advance care planning in naïve contexts - where to look when plowing new terrain?

Abstract

Background Advance care planning (ACP) is a way of applying modern medicine to the principle of patient autonomy and ensuring that patients receive medical care that is consistent with their values, goals and preferences. Robust evidence supports the benefits of ACP, but it remains an underutilized resource in most countries. This paper goes from the naïve point of view, and seeks to identify the barriers and facilitators to implementation in unfamiliarized contexts and in a whole system approach involving the clinical, institutional and policy level to improve the implementation of ACP. Methods Qualitative interviews were chosen to enable an explorative, flexible design. Qualitative interviews were conducted with 40 health care professionals and chief physicians in hospitals and in municipalities. The thematic analysis was done following Braun and Clarke’s strategy for thematic analysis. Results The main reported barriers were the lack of time and space, a lack of culture and leadership legitimizing ACP, lack of common communication systems, and unclear responsibility about who should initiate, resulting in missed opportunities and overtreatment. Policy development, public and professional education, and standardization of documentation were reported as key to facilitate ACP and build trust across the health care system. Conclusions Progressively changing the education of health professionals and the clinical culture are major efforts that need to be tackled to implement ACP in unfamiliarized contexts, particularly in contexts where patient's wishes are not legally binding. This will need to be tackled through rectifying the misconception that ACP is only about death, and providing practical training for health professionals, as well as developing policies and legislation on how to include patients and caregivers in the planning of care.

Patient preferences in geriatric wards, a survey of health care professionals’ practice, experience and attitudes

“…Proposed strategies for improvement at a clinical level are to normalize ACP conversations, team-discussion of prognosis and training in communication skills for quality and trust in clinician-patients conversations, especially in acute severe illness where the decisions have high impact [ 5 , 6 , 15 , 16 ]. Further, there is a need for leadership and operational plans at organizational- and system-levels [ 9 , 16 ].…”

“…Still, the recent literature indicates ACP has severe implementation problems with barriers such as inconsistency in effect on goal-concordant care and less integration in wards for patients admitted with acute severe illness [ 5 , 9 ]. In this study, prior to a randomized trial implementing ACP in geriatric wards, we aimed to identify to what extend HCP examine the patient and next-of kin preferences for information, involvement, and treatment and to synthesize the experience of clinical practice in accordance with these preferences.…”

Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial

“…Of 40 health care professionals and chief physicians in hospitals and community services, three had practiced ACP. Policy development, public and professional education, and standardization of documentation were reported as key factors to facilitate ACP and build trust across the health care system [ 53 ].…”

“…We have already found that the lack of time and misconceptions about ACP are main barriers to ACP at the clinical level. Providing practical training for health professionals, particularly regarding how to start ACP, are important facilitators [ 53 ]. At institutional level, standardizing how to document and communicate ACP across levels were reported as the most important facilitators, and will therefore be among the implementation strategies where the project will strive to develop sustainable solutions.…”

“…Two qualitative sub-studies include selected stakeholders to explore barriers and facilitators for ACP in a broader context. The first, already published, explores barriers and facilitators in a wider health care service context and includes health care professionals and chief physicians in hospitals and in municipalities [ 53 ]. The second explores barriers and facilitators at the municipal, regional and national level.…”