Table 3.

Thematic analysis results of open-ended survey question regarding ways to overcome barriers and make it easier for health care providers in primary care to talk with patients about ACP

Public involvement
  • Public awareness of ACP

  • Public engagement in ACP

  • Public education about limitations of life-sustaining treatments

Respondents mentioned that the public should be made aware of the importance of ACP through media, thought it should be normalized, and suggested that it is a public health issue. There was also believed to be an obligation for all health care providers in the system to ensure that patients are given honest information about life-sustaining treatments
  • “Perhaps more media attention to the importance of this issue, getting individuals to give this issue priority and to reinforce that ACP is for everyone to contemplate and execute, not just those who are very ill or very elderly” (MD)

  • “Make ACP a public health issue. Make it the norm for all healthy adults to have this conversation before illness starts” (MD)

  • “Group visits or neighbourhood forums to discuss the topic” (MD)

  • “Patients do not realize the a) lack of utility and b) potential for harm of most medical care at end of life; it is an eye opener to share it with them. I worry I sound like a conspiracy theorist when I talk about it and I am the only one they have ever heard it from!” (MD)

Health care provider attitudes
  • ACP as a part of family practice

  • Frank, honest communication with patients

Respondents described ACP as being a part of the role of the family physician in the context of providing patient-centred care in primary care; ACP was compared to routine practices such as cancer screening for preventive health
  • “Remembering that one of the most important functions of primary care is to act as the patient advocate and care coordinator. End-of-life discussion is an essential part of this management role” (MD)

  • “Discussion of ACP should be deemed as ‘mandatory’ as cancer screening is for patients on PHR. Setting an age limit on when this gets discussed on a PHR is one way to start the conversation” (MD)

Creating capacity for primary care providers
  • Training

  • Clarity of roles for MD and AHP

The need for training of family physicians and others in primary care and the need to clarify roles within the primary care practice were described. A particular need for training on how to start conversations was noted. An important role for AHPs was described; AHP noted that there should be a team approach to ACP wherein roles are clarified for the family physician and other health professionals
  • “Training in ACP. I have never received any training, therefore I do not engage in these discussions” (MD)

  • “Team training particularly with the multidisciplinary team can be useful with this” (AHP)

  • “Simple tools to provide to health care providers on how to initiate the conversation on ACP” (MD)

  • “Have MDs in clinic talk to nurses about how they want nurses to be involved with their patients about ACP. All the MDs have different ideas on who or what to discuss [with] ACP so it is difficult for nurses” (AHP)

Integration of ACP into work flow
  • Automation of patient identification

  • Available resources in practice

  • Mechanism to document

  • Mechanism of reminder

Respondents noted a need for automated (electronic) triggers to identify patients and reminders to revisit discussions within the EMR, making ACP resources for patients readily available in the practice, and a mechanism to document discussions
  • “Having a separate icon in the EMR re ACP; it could even part of [the] physical so that discussion happens with everyone” (AHP)

  • “Consistency in the forms used and their delivery—I believe this is now happening with the Green Sleeve”* (MD)

  • “Have good-quality handouts available online, in offices, posters everywhere” (MD)

System and policy support
  • Transferability of ACP

  • Remuneration for ACP

  • Policy support

Respondents provided clear direction on system and policy recommendations, suggesting the need for remuneration through billing codes and incentives that reflect the time that is required, transportability of ACP information throughout the health care system, and the need to monitor and measure the affects of this activity
  • “We need a common provincial electronic health record with a section specifically for ACP that can be updated in real time by a patient’s health care provider regardless of their location” (MD)

  • “We need to have time to have these discussions with patients and their families. This translates to the need for remuneration. We cannot forward ACP as a priority if it is not sufficiently funded despite its high level of importance. You get what you pay for” (MD)

  • “We need some way to capture the benefits of ACP discussions. If you can’t measure it then you can’t improve it. ACP might save the system millions of dollars by reducing unnecessary and unwanted tests, procedures, interventions, etc, that may only further diminish quality of life” (MD)

  • ACP—advance care planning, AHP—allied health professional, EMR—electronic medical record, MD—medical doctor, PHR—periodic health review.

  • * A Green Sleeve is a plastic pocket used in Alberta that holds advance care planning forms and that is intended to travel with the patient throughout the health care system.