Background Advance care planning (ACP) is paramount for nursing home residents, who are typically frail and of old age. In The Netherlands, medical care for nursing home residents is provided by so-called ‘elderly care physicians’ (ECPs). This study aims to gain insight in how ECPs practice ACP with nursing home residents in The Netherlands and their surrogate decision makers, in order to get a comprehensive understanding of ACP in the context of daily clinical routine.

Methods We conducted an ethnographic study at 8 locations of 2 nursing home organizations in The Netherlands. In total, 40 days of observation took place in February-March 2020 and August-November 2020 on wards for long-term stay. Field notes and day reports were written by the observer, who had regular debriefings with a senior researcher. After the observations, interviews were conducted with participating physicians (member check). Day reports and verbatim interview transcripts were coded and discussed by 3 researchers until consensus was reached.

Results ACP discussions were observed in 33 care plan evaluations, 6 nursing home admittances, and 6 other meetings between a physician and a nursing home resident’s surrogate decision maker. Observations showed that ACP was a regular agenda item at biannual care plan evaluations. However, ACP discussions were short and did result in non-explicit treatment orders such as no hospital admission if the prognosis is bad. ACP discussions were mostly used to prepare residents and their surrogates for decisions on limiting medical treatments in the future.

Conclusions This ethnographic study shows that ACP discussions are common in nursing homes in The Netherlands. The present study did not provide enough longitudinal data to draw conclusions on the effect of the observed ACP discussions on actual treatment decisions in the future.

This study was funded by the Netherlands Organisation for Health Research and Development, grant 839120002.