Advance Care Planning Conversations Research Articles

Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial

Background Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway. Method From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team. Results A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X 2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance. Conclusion With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

Advance care planning in British Columbia: awareness and engagement (2012–2020)

ObjectivesThis study examines trends in advance care planning (ACP) awareness, engagement, attitude and experiences among the public in British Columbia (BC), Canada, from 2012 to 2020. This time period is...

Participation in Advance Care Planning Among Medically At-Risk Rural Veterans: Protocol for a Personalized Engagement Model.

Many of the challenges in advanced care planning (ACP) conversations are linked to the waxing and waning progress of serious illnesses. Conversations with patients about future medical care decisions by a surrogate decision maker have historically been left until late in the patient's disease trajectory. These conversations often happen at a time when the patient is already very ill. The challenge in effective early ACP and serious illness conversations is to create a situation where patients appreciate the link between current and future medical care. Setting the stage to make these conversations more accessible includes using telehealth to have conversations at the patient's place of choice. The personalization used includes addressing the current medical and social needs of the patient and ensuring that expressed needs are addressed as much as possible. Engaging patients in these conversations allows the documentation of patient preferences in the electronic health record (EHR), providing guidelines for future medical care. The objective of our telehealth serious illness care conversations program was to successfully recruit patients who lacked up-to-date documentation of ACP in their EHR. Once these patients were identified, we engaged in meaningful, structured conversations to address the veterans' current needs and concerns. We developed a recruitment protocol that increased the uptake of rural veterans' participation in serious illness care conversations and subsequent EHR documentation. The recruitment protocol outlined herein used administrative data to determine those patients who have not completed or updated formal ACP documentation in the EHR and who are at above-average risk for death in the next 3-5 years. The key features of the telehealth serious illness care conversations recruitment protocol involve tailoring the recruitment approach to address current patient concerns while emphasizing future medical decision-making. As of September 2022, 196 veterans had completed this intervention. The recruitment method ensures that the timing of the intervention is patient driven, allowing for veterans to engage in ACP at a time and place convenient for them and their identified support persons. The recruitment protocol has been successful in actively involving patients in ACP conversations, leading to an uptick in completed formal documentation of ACP preferences within the EHR for this specific population. This documentation is then available to the medical team to guide future medical care. RR1-10.2196/55080.

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.

Advance care planning (ACP) aims to create conditions for more person-centred care. We aimed to explore variations in person-centred care discussions and treatment-centred care discussions within ACP conversations in the Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention and how person-centred care discussions could be encouraged. The MUTUAL intervention consists of the following: (i) timely patient selection, (ii) the patient and healthcare professionals preparing for the conversation, (iii) a scripted ACP conversation in a multidisciplinary setting and (iv) documentation. We conducted a narrative analysis of ACP conversations. A narrative summary template was created and used to analyse 18 audio-recordings. We noticed variations in person-centred and treatment-centred focus within the ACP conversations. We identified three important strategies that facilitated person-centred care discussions within ACP conversations. First, healthcare professionals' acceptance that ACP is an individual process. We believe it is important that healthcare professionals recognise and accept where the patient is in his or her individual ACP process; not making decisions right away can also be part of a decisional process. Secondly, exploring the underlying motivation for treatment wishes can give insights into patient's wishes, values and needs. Lastly, healthcare professionals who demonstrated an adaptive, curious and engaged attitude throughout the ACP process achieved more person-centred ACP conversations. This coincided with elaborating on the patient's emotions, fears and worries. Person-centred and treatment-centred focus varied within the ACP conversations in the MUTUAL intervention. Certain strategies by healthcare professionals facilitated a more person-centred focus.

"Call 911 - That's my [Advance Care] Plan": Factors that Inform Advance Care Planning Conversation Readiness Among Aging Persons Living With HIV.

Antiretroviral therapy has dramatically increased the lifespan of people living with HIV (PLWH), but advance care planning (ACP) and hospice services are underutilized in this population. The purpose of this study was to understand barriers and facilitators to ACP among this group. PLWH (n = 25) were recruited from an HIV Clinic at a Veterans Affairs (VA) Medical Center in Atlanta, GA to represent a range of sociodemographic characteristics and experiences. Semi-structured interviews were analyzed using thematic analysis. More than half of participants (64%) indicated not engaging in ACP. We identified four key barriers to ACP: (1) a self-image among PLWH as "survivors" (and a reluctance to think about ACP); (2) a history of mistrust and mistreatment; (3) weak social ties and a desire to avoid disclosure of HIV status; and (4) a value for self-reliance. Findings have important implications for interventions to overcome these barriers.

Advance care planning with older Norwegian adults in their homes: a narrative ethnographic study

BackgroundThe aim of advance care planning (ACP) is to enable patients to define and discuss their values and preferences to ensure that the care they receive is consistent with their needs and wishes. Most studies of ACP with older adults focus on conversations conducted in institutions. This study aimed to explore how ACP with older patients is carried out and experienced by healthcare professionals when the conversations occur in their private homes.MethodsThe data were obtained from participant observations of ACP conversations in the homes of eight older patients with advanced cancer, which also involved relatives and healthcare professionals. Additionally, ethnographic interviews were conducted with the healthcare professionals. We undertook a narrative analysis of what was said, and how the individuals acted and interacted.ResultsThe home influenced both the substance and form of the ACP conversations. The patients and relatives welcomed the healthcare professionals as guests and were encouraged to share their perceptions of their current situation, joys and worries. Their values were often implicit in their stories about past experiences. The planning mainly focused on life-prolonging treatment and the preferred future place of care. Several patients were not ready to discuss one or more ACP issues. The palliative-care-team physician addressed the patients’ readiness for ACP by asking for permission to move on to a different topic, shifting between serious and lighter topics, and using elements from the home as ‘door openers’ to continue conversations. ACP conversations were an essential basis for future palliative care and cooperation, giving important additional information about the patient and their relatives.ConclusionConducting the ACP conversations in the patients’ homes ensured a homely atmosphere that facilitated a caring approach when sensitive issues were discussed, and in turn supported the identification of important personal values. The healthcare professionals expressed that the ACP conversations represented an essential common reference point and provided a shared awareness of the expected disease trajectory and the values, preferences and needs of the patient. These findings are particularly important given that many older patients struggle to verbalize or form an opinion on issues affecting their future.

Are specialist-provided end-of-life scenarios key to initiation of advance care planning in primary care? A mixed-methods study.

Specialist-provided end-of-life scenarios (SP-EOLS) may improve advance care planning (ACP) implementation in primary care by helping overcome barriers such as uncertain prognosis and poor interprofessional collaboration. We aimed to explore the current use and potential impact of SP-EOLS on ACP in Dutch primary care. We performed a mixed-methods study. From patients discussed in a hospital-based academic palliative care multidisciplinary team meeting between 2016 and 2019 and died, we collected primary care electronic medical records data on SP-EOLS, actual EOLS, and ACP initiation and applied descriptive and comparative analyses. Subsequently, we interviewed general practitioners (GPs) and thematically analyzed the transcripts. In 69.7% of 66 reviewed patient files, SP-EOLS were found. In patients whose GP had received SP-EOLS, ACP conversations were more often reported (92.0 vs. 61.0%, p = 0.006). From 11 GP interviews, we identified 4 themes: (1) SP-EOLS guide GPs, patients, and relatives when dealing with an uncertain future perspective; (2) SP-EOLS provide continuity of care between primary and secondary/tertiary care; (3) SP-EOLS should be tailored to the individual patient; and (4) SP-EOLS need to be personalized and uniformly transferred to GPs. SP-EOLS may facilitate ACP conversations by GPs. They have the potential to help overcome existing barriers to ACP implementation by providing guidance and supporting interprofessional collaboration. Future research should focus on improving SP-EOLS and tailor them to the needs of all end users, focusing on improving their effect on ACP conversations.

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

This study sought to determine the feasibility and acceptability of a facilitated advance care planning (ACP) intervention implemented in outpatient clinics, as perceived by health-care professionals (HCPs). Data from seven focus groups (n = 27) and nine semi-structured interviews with HCPs recruited as part of a pragmatic, randomised controlled trial (RCT) were analysed using qualitative descriptive methodology. Components of the intervention included HCP education and training, tools to assist HCPs with patient selection, hardcopy information, and ACP documentation, and specialised nurse-facilitators to support HCPs to complete ACP conversations and documentation with patients and caregivers. Health-care professionals working in tertiary outpatient clinics perceived the facilitated ACP intervention as feasible and acceptable. Health-care professionals reported a high level of satisfaction with key elements of the intervention, including the specialised education and training, screening and assessment procedures and ongoing support from the nurse-facilitators. Health-care professionals reported this training and support increased their confidence and ACP knowledge, leading to more frequent ACP discussions with patients and their families. Health-care professionals noted their ability to conduct ACP screening and assessment in clinic was impeded by large clinical caseloads and patient-related factors (e.g., dementia diagnoses, and emotional distress). Additional barriers to ACP implementation identified by HCPs included poor collaboration, constrained time and clinical space, undefined roles and standardised recording procedures for HCPs. Facilitated ACP intervention in outpatient clinics is perceived by HCPs as feasible and acceptable. Addressing barriers and tailoring implementation strategies may improve the delivery of ACP as part of tertiary outpatient care.

ADVANCED CARE PLANNING: LEVERAGING PARTNERSHIPS TO IMPROVE STATE-WIDE DISSEMINATION

Abstract Rowan-Virtua School of Osteopathic Medicine, The New Jersey Institute for Successful Aging (NJISA), in collaboration with the New Jersey Division of Aging Services (DoAS) and Respecting Choices, implemented a state-wide project training workforce professionals in Advanced Care Planning (ACP) conversations with older adults. The concept: proactively leverage the long-term care management relationships in community-based, high-touch programs. NJISA identified Respecting Choices, an evidenced-based program approved by the Administration for Community Living. Respecting Choices offers standardized certification for ACP facilitators and instructors, paving a pathway for workforce sustainability. To achieve state-wide penetration, NJISA partnered with NJ DoAS to target staff and professionals serving the state aging network. NJ DoAS provided access to county-level case managers serving the Jersey Assistance for Community Caregiving (JACC) program, Program of All-Inclusive Care for the Elderly (PACE) nurses and social workers, and NJ DoAS staff. Also included in training efforts were staff from select senior affordable housing sites. With funding support through the New Jersey Health Foundation, NJISA and Respecting Choices offered virtual, live training course for certification of First Steps ACP facilitators and instructors and Design and Implementation for state aging networks, and ACP Instructors. NJ DoAS modified the electronic documentation system utilized by JACC staff to capture on-going ACP conversations and outcomes. Despite barriers and mid-course corrections, training totals include (30) certified ACP Facilitators, (3) leaders for Design and Implementation, and (5) certified ACP Instructors. Response to curriculum was positive; participants indicating greater confidence navigating ACP conversations. Future plans to continue dissemination have been discussed.

PERCEIVED BARRIERS AND SOCIOCULTURAL FACTORS OF ADVANCE CARE PLANNING AMONG CHINESE AMERICAN OLDER ADULTS

Abstract Despite documented benefits of advance care planning (ACP), persistent racial and ethnic disparities exist in ACP engagement. This study, guided by a social ecological model, examined perceived barriers and sociocultural factors associated with informal ACP conversations among Chinese American older adults. A purposive sample of 281 community-dwelling older Chinese Americans aged 55 years or older in Arizona and Maryland completed a survey in 2018. The average age of participants was 77.8 (SD = 9.4) and the average number of years living in the U.S. was 24.9 years (SD = 13.4). Most participants were first-generation immigrants (94.7%) and reported Chinese as their primary language (91.8%). About 26.5% of participants had ACP conversations with family. Hierarchical logistic regression results suggest that more perceived barriers were associated with lower odds of ACP conversations (OR = 0.87, p < 0.01). Sociocultural factors were associated with greater odds of ACP conversations, including more years in the U.S. (OR = 1.04, p = 0.02) and English language proficiency (OR = 11.85, p = 0.02). Social support had a significant moderation effect (b = -.01, p < 0.01), indicating a larger effect of perceived barriers on ACP conversations among those with lower social support. Findings highlighted the importance of language services, translated informational materials, and social support in facilitating ACP discussions among Chinese American older adults. Community-based ACP facilitators who have both language skills and cultural competence may be particularly beneficial in engaging this population. Effective ways to reduce barriers to ACP at various levels are needed.

EXPLORATION OF PREPAREDNESS FOR MEDICAL DECISION MAKING FOR FAMILY CAREGIVERS OF PEOPLE WITH DEMENTIA

Abstract As dementia progresses, many family caregivers of people with dementia (PWD) often experience increasing demands of making medical decisions for their loved ones and feel unprepared, causing severe psychological distress. This presentation explores what factors influence preparedness level of family caregivers in medical decision-making for PWD. As part of a larger two-group randomized trial in which 273 PWD-family caregiver dyads received either a control protocol or a multi-component communication intervention including advance care planning (ACP) facilitation, this qualitative study used thematic analysis methods to analyze 10 transcripts resulting from audio-recorded and transcribed ACP conversations with an ACP facilitator, PWD, and family caregivers. Interview duration was over 30 minutes. The major themes identified were: (1) knowledge about PWD’s treatment preferences, (2) experience with death and dying, (3) previous decision-making involvement, and (4) spiritual beliefs. Many family caregivers found ACP conversations with PWD about their goals of care to be beneficial in improving their confidence in making medical decisions. A few participants also reported witnessing a loved one’s suffering at the end of life or having made care decisions for family before helped them to initiate conversations with PWD about medical wishes, thus enhanced readiness for decision making. Lastly, few caregivers reported belief in God would help them make the “right decisions”. Preliminary results highlight that caregivers’ understanding of PWD’s treatment preferences helps to prepare family caregivers for decision-making, underlining the need for early and culturally appropriate ACP conversations among residents, caregivers, and clinicians.

ADVANCE CARE PLANNING IN PRIMARY CARE: ENGAGING ACCOMPANIED OLDER ADULTS WITH COGNITIVE IMPAIRMENT

Abstract Alzheimer’s Disease and Related Dementias (ADRD) are among the most profoundly disabling and costly of all health conditions, and persons living with dementia are at heightened risk for high utilization of burdensome and costly end-of-life care. Family caregivers are at the forefront of managing ADRD, however, they are not routinely engaged in primary care discussions about prognosis and the healthcare preferences of the people for whom they care. Advance care planning (ACP) is a longitudinal communication process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. Early initiation of ACP, communication with the primary care team, and the inclusion of associated caregivers is imperative in ADRD care due to progressive and devastating effects on decision-making capacity connected with the disease. SHARE, a multicomponent communication intervention, engaged 273 patient-family caregiver dyads in a randomized-controlled trial collecting baseline and six-month survey data related to experiences in the primary care setting. 145 patient-caregiver dyads assigned to the intervention received an offer for a facilitated advance care planning conversation. This symposium will highlight 6-month outcomes from caregiver-reported surveys. Attendees will gain a perspective on ACP considerations in a cognitively impaired population including ethical considerations and the factors influencing preparedness for medical decision making for involved family caregivers. Additional attention concerning the quality and content of ACP conversations with patient-caregiver dyads and the development of a fidelity tool for usage with audio-recorded ACP conversations will be presented.

ADVANCE CARE PLANNING FIDELITY TOOL IN THE CONTEXT OF COGNITIVE IMPAIRMENT: THE SHARE TRIAL

Abstract 2. Conducting high-quality advance care planning (ACP) conversations with persons living with ADRD and their family members is inherently challenging. Differing levels of cognitive function, judgment, ability to engage, and care partner involvement adds to the complexity of such ACP conversations, necessitating flexible fidelity monitoring to accommodate contextual factors. This presentation will focus on the process of measuring ACP fidelity. The SHARE ACP fidelity checklist was developed to measure the protocol adherence during ACP meetings, monitor for areas in which ACP facilitators may require re-training or additional support, and to inform analyses of the impact of the overall exposure to the study intervention. The fidelity checklist items are organized into three overarching domains: Meeting Set-Up, ACP Meeting Topics, and Facilitator Communication Skills. For the present study, a fidelity adjudication team from a pool of 7 raters, listened to and independently rated recorded conversations for protocol adherence. Each checklist item is scored ranging from 0 to 2 (0=not done; 1=needs improvement; or 2=effective) with higher scores indicating greater adherence. Fidelity ratings tended to improve over time, suggesting a facilitator experience effect. The goal to achieve an overall fidelity rating of ≥80% was met in 63% of dyad conversations. Based on subscale scores, project targets were most frequently met on the Communication Skills subscale and less frequently accomplished on the Meeting Set Up subscale. Despite some challenges, preliminary assessments of SHARE intervention fidelity appear promising, and evidence suggests the fidelity checklist is both valid and reliable.

CONDITIONS ASSOCIATED WITH SUCCESSFUL IMPLEMENTATION OF AN ADVANCE CARE PLANNING INTERVENTION IN NURSING HOMES

Abstract Implementing evidence-based interventions in nursing homes is challenging in part because clinical trials requiring a controlled experimental environment are difficult to sustain. In contrast, pragmatic clinical trials develop and evaluate evidence-based interventions in the “real world” with the goal of streamlining implementation after study completion. However, there is minimal information available identifying conditions associated with successful implementation of pragmatic interventions in the nursing home setting. The “Aligning Patient Preferences - a Role Offering Alzheimer’s patients, Caregivers, and Healthcare Providers Education and Support” (APPROACHES) project is a pragmatic trial designed to test and evaluate a staff-led advance care planning (ACP) intervention for residents with ADRD in 131 nursing homes (64 intervention, 67 control) between September 1, 2021 and August 31, 2022. ACP Specialists received training on ACP facilitation and implementation of the ACP program in the facility. Twenty of 65 (31%) sites successfully implemented the APPROACHES intervention and had > 75% of residents with documented ACP conversations. Using configurational analysis, we found two solutions directly linked with successful pragmatic implementation: (1) no executive director turnover during the observation period combined with site participation in monthly intervention support calls with ACP staff at other facilities; and (2) higher rates of hospitalization (3.96 – 7.2 per 1000 resident days) combined with a low number of certified beds. Findings suggest that leadership stability and engagement with peers were essential drivers of successful implementation. Having greater improvement opportunities as well as a more manageable caseload for the ACP Specialist may also help explain successful implementation.

PRAGMATIC IMPLEMENTATION OF AN ADVANCE CARE PLANNING INITIATIVE: MOVING KNOWLEDGE INTO ACTION

Abstract Primary care is an important setting for patient and family-centered communication with older adults given the high frequency of interactions, longitudinal trusted relationships, and patient preferences for advance care planning (ACP). Increasing ACP conversations and documentation of advance directives in primary care is a focus of quality-of-care initiatives and is particularly relevant for older adults, including those with dementia. The SHARING Choices ACP program evaluation was designed to examine the fidelity of implementation with the two partner health systems. SHARING Choices includes a mailing (introductory letter, an agenda-setting checklist, a blank advance directive, and information about shared-portal access for family) sent two weeks prior to scheduled primary care visits for patients aged 65 and above along with access to an ACP facilitator in each practice. Embedding SHARING Choices within primary care practices involved a multi-step process, including onboarding of health system partners, facilitator identification and training, tailored onboarding, practice champion engagement, and practice orientation and ongoing support. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 645 conversations occurred. Most conversations (94.8%) were less than 45 minutes in duration. Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with frontline staff; adapting implementation processes to fit the operational and organizational priorities of the health system.

ACP Conversations with Chinese and South Asian Patients: Physicians' Perspectives of Barriers and Facilitating Factors.

Advance Care Planning (ACP) discussions are infrequently conducted with physicians, even fewer among minorities. We explored physicians' experiences in engaging Chinese (CH) and South Asian (SA) patients in ACP conversations to understand initiation and participation patterns, topics covered, and barriers and facilitating factors. Twenty-two physicians with 15%+ SA patients aged 55+ and 19 with 15%+ CH patients aged 55+ were interviewed. SA- and CH-serving physicians described similar initiation patterns, cultural context, and need for standardized ACP routines. However, the SA-serving physicians described greater involvement of family members, while CH-serving physicians described more communication barriers and family members' desire to hide the diagnosis from patients. Cultural taboos surrounding discussion around death and dying appear to influence CH older adults and families strongly. Lack of familiarity with ACP amongst the SA population accounts more for their limited engagement in ACP discussions.

Perspectives of people with young-onset dementia on future quality of life: a qualitative interview study with implications for advance care planning

Introduction:Advance care planning (ACP), one of the key domains of palliative care, enables individuals to define and discuss goals and preferences for future treatment and care with family and healthcare professionals. By exploring the views of people with dementia on quality of life now and in the future, including the end of life, care provisions can be tailored to their values. The perspectives of people with young-onset dementia (YOD), with a symptom onset before the age of 65, may differ from those of older people with dementia given the different life phase and family context. Qualitative research methods can be used to elicit the attitudes and beliefs to generate insight into their perspectives.Methods:Qualitive study, as part of the Care4Youngdem-study, using semi-structured interviews with a criterion-based purposive sample of community-dwelling people with YOD (n=10) and their (family) caregivers in the Netherlands. We adapted the interview guide based on discussion of the transcripts. Double coding of three interviews resulted in a codebook. The codes were subsequently analysed through thematic analysis.Results:Interviews took place between December 2019 and February 2022. The most prevalent dementia subtype was Alzheimer’s (n=7). Four overarching themes, based on 21 categories, were derived from the interviews: (1) connectedness with others, (2) sense of dignity, (3) acceptance versus no acceptance of the impact of dementia, (4) concerning oneself with the future versus not wishing to concern oneself with the future. Connectedness with others and a sense of dignity were deemed prerequisites for (future) quality of life but were affected by YOD. These themes overlapped in terms of axial codes. Ambiguities were seen in the attitude towards the impact of YOD and the preparation for the future. The degree of acceptance of YOD affected the orientation towards the future.Discussion:Family and professional caregivers should discuss with people with YOD how to maintain connectedness with others and a sense of dignity. Opposite ways of coping with the present and future were found. Professional caregivers should take personal coping styles into account when starting ACP conversations.

"Gives peace of mind" - Relatives' perspectives of end-of-life conversations.

Planning for end-of-life (EOL) and future treatment and care through advance care planning (ACP) is being increasingly implemented in different healthcare settings, and interest in ACP is growing. Several studies have emphasized the importance of relatives participating in conversations about wishes for EOL and being included in the process. Likewise, research has highlighted how relatives can be a valuable resource in an emergency setting. Although relatives have a significant role, few studies have investigated their perspectives of ACP and EOL conversations. This study explores relatives' experiences of the benefits and disadvantages of having conversations about wishes for EOL treatment. Semi-structured telephone interviews were held with 29 relatives who had participated in a conversation about EOL wishes with a patient and physician 2 years prior in a variety of Danish healthcare settings. The relatives were interviewed between September 2020 and June 2022. Content analysis was performed on the qualitative data. The interviews revealed two themes: "gives peace of mind" and "enables more openness and common understanding of EOL." Relatives found that conversations about EOL could help assure that patients were heard and enhance their autonomy. These conversations relieved the relatives of responsibility by clarifying or confirming the patients' wishes, and they also made the relatives reflect on their own wishes for EOL. Moreover, they helped patients and relatives address other issues regarding EOL and made wishes more visible across settings. The results indicate that conducting conversations about wishes for EOL treatment and having relatives participate in those conversations were perceived as beneficial for both relatives and patients. Involving relatives in ACP should be prioritized by physicians and healthcare personnel when holding conversations about EOL.

From difficulty to meaning – Experiences of patients with advanced cancer having advance care planning conversations and a palliative care plan

PurposeThis study aimed to explore the experiences of patients with advanced cancer with Advanced care planning (ACP) communication and drawing up a palliative plan in primary healthcare settings in Norway. MethodsIn this exploratory qualitative study, data were collected using semi-structured interviews with five patients with cancer who had undergone ACP and had a palliative care plan. ResultsThe result shows three main themes with subthemes; (1) The difficult ACP conversation about cancer and death was tough, painful, and considered a “taboo.” The patients wished they had been prepared for the conversation and had it in their own homes. (2) Interactions with the doctor/nurse about the palliative care plan helped the patients feel valued and involved and brought their wishes into focus. The next of kin was present but not involved in the process. (3) Having a palliative plan was meaningful for the patients; they felt safe, and it gave them a sense of security. ConclusionsPatients with advanced cancer in a home setting in Norway experienced ACP for the preparation of a palliative plan as a process from difficulty to meaning. In this process, the context and interactions provided by the doctor/nurse and their competency in communicating with the patients and involving them as persons was important. The palliative plan gave the patients a sense of meaning, control, and safety connected to the time for the end of life.

The development of an ASCO-compliant, user-friendly electronic template to improve documentation and retrieval of advance care planning conversations: The approach of a community-based oncology practice.

36 Background: Advance Care Planning (ACP) discussions are essential components of patient care. These conversations take place routinely in oncology settings, but their documentation is time consuming and difficult to extract. Methods: Blue Ridge Cancer Care (BRCC), is certified in the ASCO/COA APC4 pilot, planned to improve its documentation of ACP discussions, and took the initiative to create a succinct, user-friendly ACP template that could be documented electronically and easily extracted for data analysis. The ASCO requirements for ACP conversations were reviewed and applied to edit an ACP template created in compliance with the Joint Commission’s requirements for the advanced certification in Palliative Care. The new template was then presented to different groups of providers in the local practice and in the larger network that the practice is part of. Results: BRCC serves about 15,000 active patients a year, with 8, 000 new consults and a total of more than 70,000 visits. The documentation of ACP conversation at the beginning of the project was 76% (n=304). Over a period of 4 months (January-April 2023) the BRCC’s Quality Programs & Process Improvement team created the new ACP template and presented it at the monthly meeting of clinical providers in three different sites. The template was also presented at one of the monthly meetings of the US Oncology Palliative Care Team. Twenty-five feedbacks were collected. There were extensive conversations about the role of different level providers in performing and documenting the conversation, i.e. physicians, Advance Care Practice Providers (APP), social workers and Nurse Navigators. The feedback process resulted in 2 edits and 3 action plans. Interestingly, the compliance increased to 83% (n=622) during this period of time, likely due to increased awareness. The form will be implemented in the coming months and the report of the results will follow. Conclusions: The development of an efficient template to document ACP conversation requires extensive feedback from users, promotes insightful discussions and strengthens providers’ engagement to ensure sustainability.