Trained facilitators’ experiences with structured advance care planning conversations in oncology: an international focus group study within the ACTION trial

Abstract

BackgroundIn oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation.MethodsA qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes.ResultsSeven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script.ConclusionsFacilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients’ preferences while staying attuned to patients’ needs.Trial registrationInternational Standard Randomised Controlled Trial Number registry 63110516 (ISRCTN63110516) per 10/3/2014.

Exploring the psychological impact of life‐limiting illness using the Attitude to Health Change scales: A qualitative focus group study in a hospice palliative care setting

“…Palliative care patients can find it difficult to raise how they are feeling about their illness (Momen et al., 2012) and expect practitioners who are looking after them to initiate the conversation (Almack et al., 2012). In this study, practitioners found using a conversational guide a positive as well as a challenging experience and similar experiences were reported in a recent advance care planning study (Zwakman et al., 2019). As indicated in our findings, the importance of training, learning by experience and having the opportunity to take part in reflective discussions was seen to increase practitioner self‐confidence (Zwakman et al., 2019).…”

“…In this study, practitioners found using a conversational guide a positive as well as a challenging experience and similar experiences were reported in a recent advance care planning study (Zwakman et al., 2019). As indicated in our findings, the importance of training, learning by experience and having the opportunity to take part in reflective discussions was seen to increase practitioner self‐confidence (Zwakman et al., 2019). The importance of being attuned to palliative care patients and family carers levels of understanding and readiness (Etkind, Bristowe, Bailey, Selman, & Murtagh, 2017) especially when using a conversational guide (Zwakman et al., 2019), such as the Attitude to Health Change scales, needs to be recognised.…”

Continue with ICU care – she is a spiritual being

“…ACP involves ongoing conversations between healthcare professionals, patients, and the patients' loved ones. The objective of these conversations is to communicate to the healthcare team the patients' wishes, values, beliefs, and goals for long-term, future medical treatment and care in advance of a medical crisis (1). Unfortunately, patients are not always receptive to these conversations and are often more focused on a cure and escalation of treatment options.…”

“…Studies have shown that ICU nurses are at high risk for moral distress due to advances in life-support technology, the intense pace of the work environment, and the constant exposure to death (5). These factors have been shown to increase the number of reported cases of moral distress among ICU nurses and related healthcare professionals (1).…”