Nurse-Led Patient-Centered Advance Care Planning in Primary Care

Abstract

Advance care planning rates remain low, indicating a need to identify an approach that promotes acceptance of, and participation in, high-quality advance care planning by clinicians, patients, and families. A pilot study was conducted to evaluate the feasibility and acceptability of a nurse-led advance care planning intervention in primary care, comparing 4 advance care planning decision aids to help patients consider options; a 4-arm, prospective, comparative design was used with scripted discussions between 4 nurses and 40 patients in a large Midwestern clinic. The study procedures were determined to be feasible and acceptable. Most invited patients agreed to participate (40 of 66, 60%); 38 of 40 completed the intervention. Overall, patients and nurses were satisfied with the intervention. Changes in scores on the engagement survey were positive, indicating improvement across all groups. According to these preliminary data, 124 patients would be required in each group for a fully powered study. In addition, 34 of 40 patients (85%) completed an advance directive; all 40 patients identified a healthcare agent. The use of nurses to facilitate advance care planning with patients may be an opportunity to improve healthcare and patient outcomes and support full-scope nursing practice in primary care settings.

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

“…Other studies found individuals with lived experience of caring for someone else at end of life, or experience with ACP had increased uptake of ACP,47 58 and this also included GPs with personal experience of ACP 31. Two studies reported the process of discussion and reflection of values over multiple visits as enabling ACP to be most effective,14 34 supported by similar findings from others 43 57 64 65…”

“…The majority of studies identifying interpersonal enablers referred specifically to the importance of the doctor–patient relationship. Enabling factors within this relationship were longevity of the association and high level of trust 14 42 48 49 61 62 64 67 72. A more recent trend is evidenced in the literature with five studies published since 2016 detailing the role of nurse–patient communication as an enabling factor in uptake of ACP.…”

“…Other studies suggested there was a need to encourage more health professional involvement in ACP 56. Nurse care coordinators have been found to be well positioned to leverage opportunities to discuss ACP with patients in primary care,14 51 64 but Fletcher et al 58 explored the role of nurses and identified the majority of nurse participants looked to the doctor for leadership in ACP (p426) and pointed to lack of role clarity in this regard across providers generally 58…”

“…Strong communication skills, confidence, knowledge and positive GP attitudes were described as enablers and achieving this was variously described through provider education and training, skills development, deliberative discussion and the clarification of GP attitudes and roles. The emerging role of the broader healthcare team, with a particular focus on extended roles of the practice nurse was evident in most recent publications 14 64 72 74…”

“…Studies explored timing the prompts preconsultation with mail out,46 during consultations as screen prompts for providers,59 and simultaneous prompts for both consumer and provider 46 68. Studies reported variable degrees of success 46 59 64 68. and those studies implementing a combination of approaches reported greater uptake of ACP than single step processes 68…”