The development and feasibility study of Multidisciplinary Timely Undertaken Advance Care Planning conversations at the outpatient clinic: the MUTUAL intervention

Abstract

Background Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. Aim To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. Methods The United Kingdom’s Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). Results We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. Conclusion This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals.

Finding the balance between person-centred and treatment-centred discussions in advance care planning—a qualitative analysis of conversations within the MUTUAL (Multidisciplinary Timely Undertaken Advance Care Planning conversations) intervention using a narrative analysis

“…The MUTUAL ACP intervention consists of four steps: timely patient selection, the patient and healthcare professionals preparing for the conversation, a scripted ACP conversation in a multidisciplinary setting (a trained nurse starting the conversation and the treating physician joining the conversation) and documentation of the conversation. An elaborate description of the development and feasibility study of the MUTUAL intervention can be found elsewhere [ 4 ]. A questionnaire was developed for patients to complete prior to the conversation.…”

“…The Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention was developed in 2018 [ 4 ]. An important element of the MUTUAL intervention is that a trained nurse starts the conversation, and is joined by the treating physician in the second part of the conversation.…”

Feasibility and acceptability of facilitated advance care planning in outpatient clinics: A qualitative study of health‐care professionals experience

“…Outpatient clinics provide an opportune environment for end-of-life treatment discussions in a less stressful setting. 7 Adapting ACP interventions to address barriers in the clinical setting has been identified as a key strategy for effective implementation. 8 Advance care planning interventions that target individual, service and system-level processes simultaneously may result in improved ACP uptake.…”

“…Outpatient clinics provide an opportune environment for end‐of‐life treatment discussions in a less stressful setting 7 . Adapting ACP interventions to address barriers in the clinical setting has been identified as a key strategy for effective implementation 8 .…”

Feasibility and Acceptability of Facilitated Advance Care Planning in Outpatient Clinics: A Qualitative Study of Patient and Caregivers Experiences

“…Few studies have assessed ACP implementation in tertiary outpatient settings. Two studies, assessing one multicomponent intervention, found the intervention to be feasible and acceptable from the perspective of HCPs (van Lummel et al, 2022(van Lummel et al, , 2023. Patient and family perceptions of ACP intervention and the extent to which this differs from current care provided in outpatient settings remains unclear.…”