Advance care planning in dementia: a qualitative study of Australian general practitioners

Abstract

As the population ages, so does the prevalence of dementia, a condition in which timely advance care planning (ACP) is recommended. This study explored the barriers and enablers of ACP for Australian GPs caring for people with dementia. Semi-structured qualitative telephone interviews informed by the theoretical domains framework (TDF) were conducted with 16 GPs from the south-east region of metropolitan Melbourne. The most prevalent domains of the TDF were: (1) environmental context and resources; (2) beliefs about consequences; and (3) social/professional role and identity. Further thematic analysis found that: (1) ACP was felt to be within the scope of general practice, but more so before the onset of dementia because lack of confidence in capacity assessment acted as a barrier once a diagnosis was made; (2) beliefs about the perceived benefits of ACP motivated GPs to engage patients in ACP; and (3) doctors felt that patients were often reluctant to discuss ACP, especially in the time-pressured context of the standard consultation. This study's use of the TDF provides direction for potential interventions to alleviate challenges faced by Australian GPs with ACP in dementia. Improving ACP in general practice may require a focus on public health campaigns to educate patients about the benefits of ACP before the onset of dementia. GPs' difficulty assessing a patient's decisional capacity may be addressed through skills development workshops.

Experiences with and perspectives on advance care planning in young- and late- onset dementia: A focus group study with physicians from various disciplines

“…In general, dementia leaves people with a relatively long timeframe of loss of ability to self-manage care and diminishing cognitive function ( Gaster et al, 2017 ). Despite ongoing discussions about the value of ACP ( Tishelman et al, 2021 ), it is argued that ACP can be particularly relevant for people with dementia and their caregivers as the condition eventually precludes patients from taking part in their own treatment decisions ( Alam et al, 2022 ). In case of Alzheimer’s Disease, diagnosis can be made during stages of mild cognitive impairment.…”

“…Fearing a shift in patients’ preferences as the condition progresses was also identified as causing reluctance for physicians to make advance decisions with people with dementia ( De Vleminck et al, 2014 ). Conversely, a qualitative study also found that beliefs about the perceived benefits of ACP can motivate physicians to engage people with dementia in the process, such as the belief that ACP would align patients’, family caregivers’ and clinicians’ care goals ( Alam et al, 2022 ).…”

“…For a more inclusive understanding of physicians’ attitudes and challenges in terms of ACP in dementia, several physician specialties that are essential in dementia diagnosis and care should be inquired. Although there is literature available, these studies mainly include general practitioners and focus exclusively on the context of late-onset dementia ( De Vleminck et al, 2014 ; Tilburgs et al, 2018b ; Alam et al, 2022 ). There is a dearth of studies that inquire physicians from various specialisms.…”