Abstract

Advance care planning (ACP) can promote person-centred care and better use of resources. ACP involving a facilitated conversation with a health or care professional is more effective than document completion alone. However, these conversations are time consuming. Evidence about how ACP support can be delivered by health and care professionals cost-effectively and at scale is currently lacking.

To explore this issue, we identified twelve international healthcare organisations with practical experience of resourcing, staffing and delivering system-wide ACP support. In each, we conducted an average 13 in-depth interviews with senior managers, ACP leads, dedicated ACP facilitators, physicians, nurses, social workers and other clinical and non-clinical staff. Data were thematically analysed using NVivo software.

Our findings emphasised the importance of strategic and dedicated day-to-day leadership for creating accountability and supporting professionals to deliver ACP support within their roles. Reliance on dedicated facilitators was not considered sustainable or scalable, although a degree of staff specialism improved efficiency and effectiveness and allowed the better targeting of training.

A lack of protected time was commonly experienced as a barrier. Incorporating ACP into existing care could mean it got ‘squeezed out’ or became too fragmented. Physician leadership was important, but entirely physician-led approaches were associated with late introduction and limited scope. Team-based approaches, involving nurses and social workers, were recommended for cost-efficiency and quality of care, and were well-aligned well with new models of care.

When used by experienced staff, the choice of ACP conversation tool had limited influence on the length of a conversation. Participants’ informational and educational needs, however, significantly influenced the time required for a conversation. There was scope for efficiencies here from the use of decision aids, educational events and activities in the community and group-based facilitations in community and clinical settings.