Barriers to ACP
An article review, MSPC Fellowship Journal ClubShivani Martin, MD Jul 4, 2023
Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning with Hospice Patients and Their Families
Background: To understand the facilitators and barriers to hospice staff engagement of patients and surrogates in advance care planning conversations.
Design and Participants: Qualitative study conducted with purposive sampling and semi structured interviews using ATLAS.ti software to assist with template analysis. Participants included 51 hospice professionals (31 clinicians, 13 leaders, and 7 quality improvement administrators) from 4 geographically distinct nonprofit US hospices serving more than 2700 people. Interview domains were derived from the implementation science framework of Capability, Opportunity, Motivation, and Behavior (COM-B), with additional questions soliciting recommendations for behavior change. Differences in themes were reconciled by consensus. The facilitator, barrier, and recommendation themes were organized within the COM-B framework.
Results: Capability was facilitated by interdisciplinary teamwork and specified clinical staff roles and inhibited by lack of self-perceived skill in engaging in advance care planning (ACP) conversations. Opportunities for ACP occurred during admission to hospice, acute changes, or deterioration in patient condition. Opportunity-related environmental barriers included time constraints such as short patient stays in hospice and workload expectations that prevented clinicians from spending more time with patients and families. Motivation to discuss ACP was facilitated by the employee's goal of providing personalized, patient-centered care. Implicit assumptions about patients' and families' preferences reduced staff's motivation to engage in ACP. Hospice staff made recommendations to improve ACP discussions, including training and modeling practice sessions, earlier introduction of ACP concepts by clinicians in pre-hospice settings, and increasing workforce diversity to reflect the patient populations the organizations want to reach and cultural competency.
Commentary: Solutions to increase behavior of ACP engagement included staff training and modeling practice sessions, introducing ACP prior to hospice, and increasing workforce diversity to improve cultural competency.1
Bottom Line: Even in hospice, clinicians expressed discomfort in discussing death and GOCs. Hospice workers identified factors to inform ACP-related behavior change interventions.
- Oh A, Allison TA, Mahoney K, et al. Front-line hospice staff perceptions of barriers and opportunities to discussing advance care planning with hospice patients and their families.J Am Med Dir Assoc. 2022;23(7). doi:10.1016/j.jamda.2021.07.014
Oh A, Allison TA, Mahoney K, et al. Front-line hospice staff perceptions of barriers and opportunities to discussing advance care planning with hospice patients and their families. J Am Med Dir Assoc. 2022;23(7). doi:10.1016/j.jamda.2021.07.014