RF3-B Barriers and Enablers to Advance Care Planning with Patients in Primary Care: A Survey of Clinicians

Howard, Michelle; Bernard, Carrie; Klein, Doug; Tan, Amy; Slaven, Marissa; Barwich, Doris; You, John J.; Asselin, Gabriel; Simon, Jessica; Heyland, Daren K.

doi:10.1016/j.jpainsymman.2016.10.053

Cited by 73 publications

(122 citation statements)

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“…12,13 A substantial proportion of patients have thought about their preferences for future health care [14][15][16] ; however, advance care planning conversations do not happen routinely between patients and health care clinicians in primary care or cancer care settings [15][16][17][18] because of system constraints. [19][20][21] Tools that increase engagement in advance care planning in a variety of patient populations and require few resources to implement are of interest. Although there are numerous publicly available tools that could be introduced in clinical settings, 22,23 few have been evaluated for their real-world effectiveness in increasing advance care planning engagement.…”

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confidence: 99%

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

Howard¹,

Robinson²,

McKenzie³

et al. 2020

Ann Fam Med

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PURPOSE Online programs may help to engage patients in advance care planning in outpatient settings. We sought to implement an online advance care planning program, PREPARE (Prepare for Your Care; http://www. prepareforyourcare.org), at home and evaluate the changes in advance care planning engagement among patients attending outpatient clinics. METHODS We undertook a prospective before-and-after study in 15 primary care clinics and 2 outpatient cancer centers in Canada. Patients were aged 50 years or older (primary care) or 18 years or older (cancer care) and free of cognitive impairment. They used the PREPARE website over 6 weeks, with reminders sent at 2 or 4 weeks. We used the 55-item Advance Care Planning Engagement Survey, which measures behavior change processes (knowledge, contemplation, self-efficacy, readiness) on 5-point scales and actions relating to substitute decision makers, quality of life, flexibility for the decision maker, and asking doctors questions on an overall scale from 0 to 21; higher scores indicate greater engagement. RESULTS In total, 315 patients were screened and 172 enrolled, of whom 75% completed the study (mean age = 65.6 years, 51% female, 35% had cancer). The mean behavior change process score was 2.9 (SD 0.8) at baseline and 3.5 (SD 0.8) at follow-up (mean change = 0.6; 95% CI, 0.49-0.73); the mean action measure score was 4.0 (SD 4.9) at baseline and 5.2 (SD 5.4) at follow-up (mean change = 1.2; 95% CI, 0.54-1.77). The effect size was moderate (0.75) for the former and small (0.23) for the latter. Findings were similar in both primary care and cancer care populations. CONCLUSIONS Implementation of the online PREPARE program in primary care and cancer care clinics increased advance care planning engagement among patients.

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confidence: 99%

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

Howard¹,

Robinson²,

McKenzie³

et al. 2020

Ann Fam Med

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“…Barriers cited by clinicians include the following: clinicians' concern about the time and other resources it takes to discuss ACP, concerns about transferring patients' documents about ACP, clinician skills in communicating about vague requests from patients, loss of interactions with patients as they enter the end of life, clinician concerns about finding the right time to discuss these issues, patients' lack of understanding limitations and complications of life-sustaining treatments, and clinician concerns about impacting patient hope. 9,10 Little is known about the characteristics of PCP or their practices in relation to how commonly they engage patients in ACP conversations. Small studies suggest that physician age (evidence for both younger and for older physicians) and also physician experience with ACP, either personally or professionally, seem more likely to routinely engage patients.…”

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confidence: 99%

Features of U.S. Primary Care Physicians and Their Practices Associated with Advance Care Planning Conversations

Nowels

Sheffler

et al. 2019

J Am Board Fam Med

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Introduction: Primary care practices are essential settings for Advance Care Planning (ACP) conversations with patients. We hypothesized that such conversations occur more routinely in Advanced Primary Care/Patient Centered Medical Home (APCP/PCMH) Practices using practice transformation strategies. Methods: We analyzed characteristics of physician respondents and their practices associated with ACP discussions in older and sicker patients using US data from the 2015 Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations. The primary outcome was how routinely these ACP conversations are reported. We developed an index of APCP/PCMH features as a practice covariable. Results: Respondents (N ‫؍‬ 1001) were predominantly male (60%) and >45 years old (74%). Multivariable analyses showed that suburban practice location was associated with fewer ACP conversations; working in a practice commonly seeing patients with multiple chronic conditions or who have palliative care needs, and working in a practice from which home visits are made, were associated with more ACP conversations. Physicians compensated in part by capitation were more likely to report ACP conversations. No association was found between a single item asking if the practice was an APCP/PCMH and having ACP conversations. However, higher scores on an index of APCP/PCMH features were associated with more ACP conversations. Conclusions: In this sample of US primary care physicians, the types of patients seen, practice location, and physician compensation influenced whether physicians routinely discuss ACP with patients who are older and sicker. Practices demonstrating more features of APCP/PCMH models of primary care are also associated with ACP discussions.

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“…Family doctors are aware that more time is needed to allow for ACP discussions. [33,[36][37][38] Indeed time has been described as the "ultimate barrier" to creating the best possible circumstances for a "good death" in one study of family physicians' experiences of conflict with substitute decision-makers. [39] Given the ongoing longitudinal relationships that exist between family physicians and their patients, seeing ACP as a process as opposed to a one-time conversation could help to manage the time-related pressures perceived in the context of individual appointments.…”

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confidence: 99%

Addressing Patient-Reported Barriers to Advance Care Planning in Family Practice

Bernard

Tan

Slaven

et al. 2019

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Background Although patient-centred care has become increasingly important across all medical specialties, when it comes to end of life care, research has shown that treatments ordered are not often concordant with people’s expressed preferences. Patient and family engagement in Advance Care Planning (ACP) in the primary care setting could improve the concordance between patients’ wishes and the healthcare received when patients cannot speak for themselves. The aim of this study was to better understand the barriers faced by older patients regarding talking to their family members and family physicians about ACP. Methods In this multi-site cross-sectional study, three free text questions regarding reasons patients found it difficult to discuss ACP with their families or their family physicians were part of a self-administered questionnaire about patients’ knowledge of and engagement in ACP. The questionnaire, which included closed ended questions followed by three probing open ended questions, was distributed in 20 family practices across 3 provinces in Canada. The free text responses were analyzed using thematic content analysis and form the basis of this paper. Results 102 participants provided an analyzable response to the survey when asked why they haven’t talked to someone about ACP. 254 answered the question about talking to their physician and 340 answered the question about talking to family members. Eight distinct themes emerged from the free text response analysis: 1. They were too young for ACP; 2. The topic is too emotional; 3. The MD should be responsible for bringing up ACP 4. A fear of negatively impacting the patient-physician relationship; 5. Not enough time in appointments; 6. Concern about family dynamics; 7. It’s not a priority; and 8. A lack of knowledge about ACP. Conclusions Patients in our sample described many barriers to ACP discussions, including concerns about the effect these discussions may have on relationships with both family members and family physicians, and issues relating to patients’ knowledge and interpretation of the importance, responsibility for, or relevance of ACP itself. Family physicians may be uniquely placed to leverage the longitudinal, person- centred relationship they have with patients to mitigate some of these barriers.

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RF3-B Barriers and Enablers to Advance Care Planning with Patients in Primary Care: A Survey of Clinicians

Cited by 73 publications

References 0 publications

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

Effect of an Interactive Website to Engage Patients in Advance Care Planning in Outpatient Settings

Features of U.S. Primary Care Physicians and Their Practices Associated with Advance Care Planning Conversations

Addressing Patient-Reported Barriers to Advance Care Planning in Family Practice

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