Advance Care Planning Practices Research Articles

Situation, Education, Innovation, and Recommendation: A Large-Scale Systematic Review of Advance Care Planning in the Age of COVID-19.

The COVID-19 pandemic highlighted the need for advance care planning (ACP) as a way to help mitigate the various care concerns that accompanied the healthcare crisis. However, unique obstacles to typical ACP practice necessitated the need for guidance and innovation to help facilitate these vital conversations. The aim of this systematic review was to identify the various ACP barriers and facilitators that arose during the pandemic and determine how ACP practice was affected across different contexts and among different populations. This systematic review (PROSPERO registration number: CRD42022359092), which adheres to the PRISMA guidelines for reporting systematic reviews, examined studies on ACP in the context of the COVID-19 pandemic. The review involved searches of five databases, including MEDLINE and Embase. Of the 843 identified studies, 115 met the inclusion criteria. The extracted ACP barriers and facilitators were codified and quantified. The most frequently occurring ACP barrier codes were: Social distancing measures and visitation restrictions, Uncertainty surrounding the COVID-19 prognosis, and Technological/Telehealth barriers. The most frequently occurring ACP facilitator codes were the following: Telehealth/virtual ACP platforms, Training for clinicians, and Care team collaboration. Identifying the ACP barriers and facilitators is essential for developing effective, resilient ACP promotion strategies and improving its delivery, accessibility, and acceptability.

Summary of evidence to facilitate the implementation of advance care planning among advanced cancer patients.

Advance care planning (ACP) is designed to ensure that patients lacking autonomous decision-making capacity receive medical services in accordance with their expectations and preferences. Individuals with advanced cancer are a crucial target for ACP implementation. However, the current practice of ACP in this group in China is suboptimal, demanding high-quality implementation evidence to strengthen ACP in the clinical practice of patients with advanced cancer. The existing literature can be summarized into 27 pieces of evidence across 7 dimensions, including initiation time, intervention content, intervention providers, intervention modalities, communication skills, outcome indicators, and environmental support. The aforementioned evidence could provide crucial support for improving ACP implementation for patients with advanced cancer. Subsequent research efforts should integrate patient preferences and explore the most suitable implementation strategies for ACP in the Chinese population with advanced cancer, considering diverse aspects such as traditional culture, ACP education and training, legislative support, and healthcare system refinement.

Reliability and Validation Study of Advance Care Planning Practice Scale among Health and Social Care Professionals.

Advance care planning (ACP) is a crucial process in clinical practice, enabling individuals to articulate their care preferences and goals, with significant implications for future healthcare. However, ACP practice of health and social care professionals (HSCPs) concerning patients, or their family members are rarely explored. The objective of the study was to adapt and validate a four-item scale assessing ACP practices of HSCPs toward patients or their family members. The ACP Practice Scale was evaluated through a cross-sectional online survey administered to HSCPs in Macao, assessing its factor structure, validity, and reliability. Based on a sample of 186 valid responses, the ACP Practice Scale demonstrated satisfactory levels of validity and reliability among HSPCs in Macao. The four-item scale explained 65.87% of the variance in ACP practice and exhibited strong internal consistency, with Cronbach's alpha and McDonald's omega coefficients of 0.82. Furthermore, item factor loadings ranged from 0.71 to 0.90. The ACP Practice Scale provides reliable and valid measurements of ACP practice among HSCPs. This instrument can help to enhance our understanding of ACP practices in clinical settings and support the advancement of advance care planning.

Oncology nurses' knowledge, attitudes, and practice behaviours towards advance care planning: A nationwide cross-sectional study

BackgroundWith the increasing cancer prevalence in China, discussions surrounding end-of-life care have become more frequent within the purview of oncology nursing. Nonetheless, limited research has explored the current state of Advance Care Planning (ACP) among oncology nurses in China. Hence, it is essential to comprehensively assesses oncology nurses' ACP knowledge, attitudes, and practice behaviours, addressing existing literature gaps and revealing China's oncology nursing ACP status. ObjectivesTo explore oncology nurses' knowledge, attitudes, and practice behaviours regarding ACP and identify factors impacting ACP practice behaviours. DesignA multi-centre, observational, cross-sectional study. SettingsThe research is conducted in oncology hospitals across 22 provinces, 4 municipalities, and 5 autonomous regions across China. ParticipantsConvenience sampling was used to recruit 1800 registered oncology nurses. MethodsData were collected via an electronic questionnaire between December 2021 and January 2022. Univariate and hierarchical multiple regression analyses were used for data prediction (P < 0.05). ResultsIn the knowledge section, respondents achieved an average accuracy rate of 51.94 % and demonstrated moderate positive attitudes towards ACP. Their practice behaviour scores were moderately graded. Sociodemographic characteristics and attitude were included as predictors of practice behaviour in the hierarchical multiple regression analysis, explaining 12.2 % and 31.1 % of the variance, respectively. The final model accounted for 43.3 % of the variance. The results indicated that attitudes had a significant and positive impact on practice behaviours, indicating that nurses with more positive attitudes were more likely to engage in ACP practice. ConclusionsChinese oncology nurses seem to have more positive attitudes towards ACP, but they do not prepare adequately in practice. By enhancing workplace values, beliefs, and policies, it is feasible to enhance the attitudes of oncology nurses towards ACP and, consequently, promote practice behaviours. Furthermore, this study underscores the need for targeted interventions to bridge the gap between positive attitudes and actual ACP implementation among oncology nurses in China.

Practice Patterns of Medical Oncologists: A Survey of Advance Care Planning in the Outpatient Setting

Introduction. Advance care planning (ACP) is an important part of cancer care. We determined the ACP practice patterns of medical oncologists at our academic cancer centre in Canada. Methods. Medical oncologists were invited to participate in a questionnaire in August 2019. Questions were validated by a local survey expert. Twelve multiple-choice questions were included. Results. Seventeen of the 23 eligible oncologists responded. 64% were male, and 76% were in practice for &lt;16 years. Common tumour sites treated by respondents included breast (53%), lung (24%), gastrointestinal (24%), and genitourinary (24%) cancers. Oncologists responded that components of ACP included designating a substitute decision-maker (100%), determining goals of care (100%), making decisions about cardiopulmonary resuscitation (94%), and disposition of property/finances (88%). They discuss ACP with curable vs. incurable patients 6% vs. 93% of the time. While 88% of oncologists reported it would be desirable to initiate ACP discussions in the first 3 visits, in the incurable setting, only 29% reported doing so. Patient characteristics that prompt oncologists to discuss ACP in the first 3 visits in the curative vs. incurable settings include elderly age (23% vs. 59%), poor performance status (47% vs. 88%), and short prognosis (47% vs. 88%). Oncologists thought the most appropriate time to discuss ACP in the curative setting was at the time the patient initiates it (35%), and during visits 2-3 in the incurable setting (41%). The most common barriers to discussing ACP include insufficient time (71%) and too much information for the patient (71%). Conclusions. While medical oncologists believe that discussing ACP with cancer patients in the first few outpatient visits is important, this seldom occurs due to the presence of several barriers.

Advance Care Planning Practice Patterns Before and During a Pandemic.

Introduction: The COVID-19 pandemic resulted in introspection of the United States health care infrastructure, especially with advance care planning (ACP). Methods: This is a retrospective chart review assessing the frequency of ACP discussions and formal documents reflecting ACP wishes in an outpatient palliative medicine (PM) practice. The study site was at University Medical Center New Orleans from pre-COVID-19 surge (November 2019-February 2020) to months during and post-COVID-19 surge (March-April 2020). Results: Results showed an increase in ACP discussions during the post-COVID-19 months. Patients seen during the surge and post-COVID-19 months were more likely to discuss medical power of attorney (odds ratio [OR] = 1.78, p = 0.045) and preferred code status (OR = 2.82, p < 0.001). Conclusion: Our study showed that more ACP discussions were conducted post-COVID-19 versus pre-COVID-19. However, formal documents reflecting these wishes were lacking. These results can help guide ACP use in crisis periods and improve understanding of ACP discussions in an outpatient PM clinic.

User appraisal of a booklet for advance care planning in multiple sclerosis: a multicenter, qualitative Italian study

ObjectivesImplementation of advance care planning (ACP) in people with progressive multiple sclerosis (PwPMS) is limited. We aimed to involve users (PwPMS, significant others, and healthcare professionals involved in PwPMS care) in the evaluation and refinement of a booklet to be used during the ACP conversations.MethodsThis qualitative study consisted of cognitive interviews with PwPMS and significant others and a focus group with healthcare professionals from three Italian centers. We analyzed the interviews using the framework method and the focus group using thematic analysis.ResultsWe interviewed 10 PwPMS (3 women; median age 54 years; median Expanded Disability Status Scale score 6.0) and three significant others (2 women; 2 spouses and one daughter). The analysis yielded three themes: booklet comprehensibility and clarity, content acceptability and emotional impact, and suggestions for improvement. Twelve healthcare professionals (7 neurologists, 3 psychologists, one nurse, and one physiotherapist) participated in the focus group, whose analysis identified two themes: booklet’s content importance and clarity and challenges to ACP implementation. Based on analysis results, we revised the booklet (text, layout, and pictures) and held a second-round interviews with two PwPMS and one significant other. The interviewees agreed on the revisions but reaffirmed their difficulty in dealing with the topic and the need for a physician when using the booklet.ConclusionsAppraisal of the booklet was instrumental in improving its acceptability and understandability before using it in the ConCure-SM feasibility trial. Furthermore, our data reveal a lack of familiarity with ACP practice in the Italian context.

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned.

The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice. We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus. From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems. The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Advance Care Planning and palliative care for patients with advanced cancer in Uganda

The study sought to identify the extent to which Advance Care Planning (ACP) is practised by palliative care health professionals providing care to patients with advanced cancer and their families in Uganda.A mixed methods study design using qualitative and quantitative methods was used for the assessment. In-depth interviews with a group of nine highly experienced health professionals were conducted using a semi-structured interview guide. Quantitative data were retrieved and analysed from a survey administered to 124 health professionals of whom only 57 (45.9%) responded. The qualitative data were analysed using inductive thematic analysis and descriptive analysis was used for the quantitative data.Of the 57 health professionals who participated in the survey, 87% were aware of ACP and 55% reported regular practice. Fifty-five (55%) percent reported regular provision of ACP for their patients and 46% reported engaging in informal ACP practices. However, 58.5% resp. 37.5% reported that they routinely provide ACP to more than 50% resp. 75% of their patients. A group of nine highly experienced palliative care professionals had a pooled ACP prevalence of only 1.2%. There was a generally good attitude towards ACP with 98.2% acknowledging that patients should be able to determine their future care. However, 32% reported being uncomfortable withholding or withdrawing life sustaining treatment. There are a number of socio-cultural beliefs and barriers, for instance that discussing death and dying is a “taboo”, as well as witchcraft, family influence in decision-making, religious beliefs that do not agree with palliative care practices and a preference to use aggressive treatment like chemotherapy for terminally ill, etc. Institutional barriers like lack of a legal framework for ACP, limited time for health professionals to engage in ACP and other patient factors such as denial of diagnosis and collusion to withhold information from patients were reported by 78.2% resp. 84% of the respondents.Despite the good awareness and attitude to ACP, there is a range of barriers that are affecting the implementation of ACP in Uganda. There is need for development of a legal framework for ACP, more research to understand the contextual barriers and develop appropriate education and public sensitisation programs.

Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis

BackgroundEvidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines...

Advance Care Planning in Belgium

This paper aims to 1) describe current levels of Advance Care Planning (ACP) development since 2002 in Belgium, 2) report on challenges and opportunities to inspire other countries with similar contextual characteristics and 3) support further development of ACP practice and research in Belgium. To address these aims, we consulted local researchers, 12 domain experts and (grey) literature (regulatory documents, reports, policy documents and practice guidelines) on ACP, palliative care, and related healthcare topics. Since 2002, when the Patient’s Right Law was passed in the federal Parliament, Belgium has had a specific medicolegal context for ACP. Initiatives to improve the uptake of ACP have been taken, e.g. standardised documentation, reimbursement codes for physicians provided by the government, and implementation of quality indicators in hospitals and nursing homes. Most of these initiatives are grassroots or predominantly oriented towards a single group of professions, e.g. general practitioners, disregarding the role that other professions can play. The patient groups most often targeted are those with cancer and older adults. Limited but growing attention is given to those with low health literacy or other minority groups. Main barriers to ACP in Belgium are: no unified platform to exchange outcomes of ACP discussions or advance directives between healthcare professionals and though efforts are made, ACP is still predominantly oriented towards documentation.

Timing and setting of billed advance care planning among Medicare decedents in 2017-2019.

The Centers for Medicare & Medicaid Services (CMS) began to reimburse clinicians for advance care planning (ACP) discussions, effective January 1, 2016. We sought to characterize the timing and setting of first-billed ACP discussions among Medicare decedents to inform future research on ACP billing codes. Using a random 20% sample of Medicare fee-for-service beneficiaries aged 66 years and older who died in 2017-2019, we described the timing (relative to death) and setting (inpatient, nursing home, office, or outpatient with or without Medicare Annual Wellness Visit [AWV], home or community, or elsewhere) of the first-billed ACP discussion for each beneficiary. Our study included 695,985 decedents (mean [SD] years of age, 83.2 [8.8]; 54.2% female); the proportion of decedents who had at least one billed ACP discussion increased from 9.7% in 2017 to 21.9% in 2019. We found that the proportion of first-billed ACP discussions held during the last month of life decreased from 37.0% in 2017 to 26.2% in 2019, while the proportion of first-billed ACP discussions held more than 12 months before death increased from 11.1% in 2017 to 35.2% in 2019. We also found that the proportion of first-billed ACP discussions held in the office or outpatient setting along with AWV increased over time (from 10.7% in 2017 to 14.1% in 2019), while the proportion held in the inpatient setting decreased (from 41.7% in 2017 to 38.0% in 2019). We found that with increasing exposure to the CMS policy change, uptake of the ACP billing code has increased; first-billed ACP discussions are occurring sooner before the end-of-life stage and are more likely to occur with AWV. Future studies should evaluate changes in ACP practice patterns, rather than only an increasing uptake in ACP billing codes, following the policy implementation.

Survey of Advance Care Planning Practices in Elderly COVID-19 Patients: A Multicenter Questionnaire Survey.

Objective Advance care planning (ACP) is a process in which the patient and family discuss end-of-life care in advance with healthcare providers in case decisional ability declines. Due to the rapid deterioration of symptoms and isolation for treatment, it is not easy for COVID-19 patients to discuss their end-of-life care with families and medical staff. We conducted a questionnaire survey to assess the current situation of ACP practices in hospitalized COVID-19 patients. Materials and methods Multicenter questionnaire surveys of hospitalized COVID-19 patients aged ≥60 years between January 2021 and August 2022 were conducted in two hospitals. The questionnaires assessed whether patients had discussed end-of-life medical treatment with their families and family physicians at the time of admission and their preferences for end-of-life medical treatments. Results A total of 109 patients aged 60-99 years (median 75.0 years) were enrolled. Only eight patients (7.3%) had practiced ACP at the time of admission. Age was a significant factor related to ACP practices (p=0.035). Although there was no significant difference between the ACP and non-ACP practiced groups for each end-of-life care, all eight patients in the ACP-practiced group were able to make decisions for all the end-of-life medical treatment, while 40 patients (33.0%) in the non-ACP-practiced group did not, showing a significant difference (p=0.026). Conclusion In hospitalized COVID-19 patients, the rate of ACP practice was as low as 7.3%. Awareness of ACP practice is necessary, especially for elderly patients with underlying diseases.

Surgeons' perception of chance of cure predicts advance care planning practices in PDAC

Background: The optimal timing and setting for advance care planning (ACP) discussion is not well outlined for patients with high-risk malignancies, such as pancreatic ductal adenocarcinoma (PDAC), who undergo curative intent resection. Cancer patients prefer to have ACP discussions with their primary care provider given their familiarity and desire to have these discussions earlier in their disease course. The aim of this study is to evaluate surgeons’ practices regarding the timing and setting for ACP.

Advance Care Planning in Serious Illness: A Narrative Review.

Advance care planning (ACP) intends to support person-centered medical decision-making by eliciting patient preferences. Research has not identified significant associations between ACP and goal-concordant end-of-life care, leading to justified scientific debate regarding ACP utility. To delineate ACP's potential benefits and missed opportunities and identify an evidence-informed, clinically relevant path ahead for ACP in serious illness. We conducted a narrative review merging the best available ACP empirical data, grey literature, and emergent scholarly discourse using a snowball search of PubMed, Medline, and Google Scholar (2000-2022). Findings were informed by our team's interprofessional clinical and research expertise in serious illness care. Early ACP practices were largely tied to mandated document completion, potentially failing to capture the holistic preferences of patients and surrogates. ACP models focused on serious illness communication rather than documentation show promising patient and clinician results. Ideally, ACP would lead to goal-concordant care even amid the unpredictability of serious illness trajectories. But ACP might also provide a false sense of security that patients' wishes will be honored and revisited at end-of-life. An iterative, 'building block' framework to integrate ACP throughout serious illness is provided alongside clinical practice, research, and policy recommendations. We advocate a balanced approach to ACP, recognizing empirical deficits while acknowledging potential benefits and ethical imperatives (e.g., fostering clinician-patient trust and shared decision-making). We support prioritizing patient/surrogate-centered outcomes with more robust measures to account for interpersonal clinician-patient variables that likely inform ACP efficacy and may better evaluate information gleaned during serious illness encounters.

ADVANCE CARE PLANNING FOR SPANISH-LANGUAGE SPEAKERS: PATIENT, FAMILY, AND INTERPRETER PERSPECTIVES

Abstract Language access is a challenge to advance care planning (ACP). Spanish-language speakers are the largest non-English speaking population in the US. While ACP tools have been translated into Spanish, it is unclear how heterogeneity in country of origin may affect the generalizability of translations across diverse US Spanish-speaking populations. The study objective is to describe challenges and facilitators to ACP for diverse populations of Spanish-language speakers. We conducted 3 focus groups with a total of 29 participants from members of Spanish-language speaking communities whose countries of origin were predominantly from the Caribbean, Central, and South America. Eligibility included being 18 years or older, being a native Spanish-speaker, and having direct experience with ACP as a patient, caregiver, or medical interpreter. We conducted thematic analysis with axial coding. Themes include: 1. Linguistic Challenges with Current ACP Translations; 2. Effect of Country of Origin and Culture on ACP Understanding; 3. Impact of Local Healthcare System Cultural on ACP; and 4. Need for ACP to be Normalized into the Local Community. ACP is both a cultural practice and a clinical practice. Recommendations for improving ACP completion for non-English speakers extend far beyond translation, since simply translating ACP tools without a cultural context is neither equitable nor inclusive. A key step is normalizing ACP into the local community. Understanding the intersection of local healthcare systems of ACP practice with the patient’s and family’s cultures of origin will facilitate introducing ACP in a culturally sensitive manner.

Psychometric evaluation of the Chinese version of advance care planning self-efficacy scale among clinical nurses

BackgroundNurses are one of the most critical members of advance care planning (ACP) discussion. The evaluation of ACP self-efficacy is of great significance for developing targeted ACP interventions among clinical nurses and update their professional roles. However, there are few instruments to evaluate their ACP self-efficacy in mainland China. The purpose of this study was to translate the ACP self-efficacy scale into Chinese and evaluate its psychometric properties among clinical nurses.MethodsA methodological study of the translation and validation of the ACP self-efficacy scale was conducted from January to March 2022. It involved three phases: (1) the translation and revision of the scale; (2) the exploration and evaluation of the item (n = 436); (3) the psychometric evaluation of the scale (n = 674).ResultsAfter a rigorous translation and revision, the ACP self-efficacy scale with three dimensions and 16 items was finally formed. In this study, the critical ratios of the item ranged from 8.226 to 17.499, and the item-total correlation coefficients ranged from 0.437 to 0.732, and the factor loadings of the item ranged from 0.638 to 0.882. The content validity index of the scale was 0.946. Supported by the eigenvalues, the three-factor structure explained the cumulative 61.131% of the overall variance. As the results of confirmatory factor analysis, all the recommended fitting indexes were appropriate. The average variance extracted values ranged from 0.570 to 0.756, and the composite reliability values ranged from 0.858 to 0.925. The total Cronbach's α coefficient, split-half reliability coefficient and test–retest reliability coefficient of the scale were 0.896, 0.767 and 0.939, respectively.ConclusionThe Chinese version of ACP self-efficacy scale was successfully introduced into China, showing good psychometric properties among clinical nurses, and can effectively assess the ACP self-efficacy. Also, the scale can provide nursing educators with a significant strategy to develop ACP educational procedure and post-intervention measures for clinical nurses to improve nurse-led ACP practice.

Evaluation of an advance care planning training program for practice professionals in Japan incorporating shared decision making skills training: a prospective study of a curricular intervention

BackgroundWe developed a novel training program for health care professionals that incorporated shared decision making (SDM) skills training into an advance care planning (ACP) training course, the first in Japan. This study aimed to assess the training program’s impact on health care professionals’ knowledge, skill, attitudes, and confidence to initiate ACP.MethodsUsing the novel Japanese educational program, we evaluated the effect of 8-month programs conducted eight community training sites of professionals who can practice ACP in a local area in Aichi Prefecture (the Aichi ACP Project). SDM skills training was provided during the workshops conducted in the ACP training course, and the participants’ satisfaction and understanding of the training were assessed. After the completion of two workshops, information on SDM skill results from the training and submitted assignments were collected anonymously from the training sites.ResultA total of 404 participants completed all education programs. After the first workshop, at least 95% of trainees stated that they were satisfied with the training and that it was useful for ACP practice. The evaluation of the results between the first and second workshops indicated improvement in SDM skills on some items of the SDM measures. In the second workshop, at least 90% of participants submitted implementation reports, and after the second workshop, a survey of confidence in ACP practice was administered, with responses indicating improvement. There were high levels of interest in education related to the ACP practices of oneself and others.ConclusionsThis educational program can be an effective for developing professionals who can practice ACP with SDM skills.

Interdisciplinary staff perceptions of advance care planning in long-term care homes: a qualitative study

BackgroundResidents living in long-term care homes (LTCH) have complex care needs, multiple chronic conditions, increasing frailty and cognitive impairment. A palliative approach that incorporates advance care planning (ACP) should be integrated with chronic disease management, yet it is not a norm in most LTCHs. Despite its growing need, there remains a lack of staff engagement in the ACP process.ObjectivesThe aim of this study was to explore the perceptions and experiences of interdisciplinary staff related to the practice of ACP in LTCHs.MethodsThis study is part of a larger Canadian project, iCAN ACP, that aims to increase uptake, and access to ACP for older Canadians living with frailty. An exploratory qualitative design using an interpretive descriptive approach was employed utilizing focus groups and semi-structured interviews with staff from four LTCHs in Ontario, Canada.FindingsThere were 98 participants, including nurses (n = 36), physicians (n = 4), personal support workers (n = 34), support staff (n = 23), and a public guardian (n = 1). Three common themes and nine subthemes were derived: a) ongoing nature of ACP; b) complexities around ACP conversations; and c) aspirations for ACP becoming a standard of care in LTCHs.DiscussionThe findings of this study provide important contributions to our understanding of the complexities surrounding ACP implementation as a standard of practice in LTCHs. One of the critical findings relates to a lack of ACP conversations prior to admission in the LTCHs, by which time many residents may have already lost cognitive abilities to engage in these discussions. The hierarchical nature of LTCH staffing also serves as a barrier to the interdisciplinary collaboration required for a successful implementation of ACP initiatives. Participants within our study expressed support for ACP communication and the need for open lines of formal and informal interdisciplinary communication. There is a need for revitalizing care in LTCHs through interdisciplinary care practices, clarification of role descriptions, optimized staffing, capacity building of each category of staff and commitment from the LTCH leadership for such care.ConclusionThe findings build on a growing body of research illustrating the need to improve staff engagement in ACP communication in LTCHs.

Exploring the Attitudes and Needs of Advance Care Planning Practice Among the Working Generation

Exploring the Attitudes and Needs of Advance Care Planning Practice Among the Working Generation