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Fidelity is fundamental: intervention predictors in advance care plans in terminal cancer
  1. Lisa Vaccaro1,
  2. Phyllis N Butow1,
  3. Deborah Lee2,
  4. Stephanie B Johnson3,
  5. Melanie Bell4,
  6. Josephine Clayton5,
  7. Karen Margaret Detering6,7 and
  8. Martin Tattersall8
  1. 1 School of Psychology, Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, New South Wales, Australia
  2. 2 School of Psychology, Centre for Medical Psychology and Evidence-based Decision-making, University of Sydney, Sydney, New South Wales, Australia
  3. 3 Nuffield Department of Population Health, Wellcome Centre for Ethics and Humanities and Ethox Centre, University of Oxford, Oxford, UK
  4. 4 Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, USA
  5. 5 Centre for Learning & Research in Palliative Care, Hammond Care, Greenwich Hospital and University of Sydney, Sydney, New South Wales, Australia
  6. 6 Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia
  7. 7 Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
  8. 8 Department of Medical Oncology, University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
  1. Correspondence to Professor Phyllis N Butow, School of Psychology, University of Sydney Lifehouse Level 6-North C39Z, Sydney, NSW 2006, Australia; phyllis.butow{at}sydney.edu.au

Abstract

Objectives Assessing whether interventions are implemented as intended (fidelity) is critical to establishing efficacy in clinical research yet rarely applied in advance care planning (ACP) interventions. We aimed to develop and implement a fidelity audit tool for an ACP intervention.

Methods We developed a fidelity audit tool assessing: (A) content; (B) quality (general communication, eliciting EOL preferences and prognostic communication); and (C) family/caregiver involvement. We audited (double-coded) 55 audio-recordings of ACP discussions delivered to advanced cancer patients and caregivers, within a clinical trial.

Results Fidelity to content was high: mean=9.38/11 but lower for the quality of general communication (mean=12.47/20), discussion of patient preferences (mean=4.67/7), prognosis (mean=3.9/6) and family/caregiver involvement (mean=2.67/4). Older patient age and caregiver religiosity were associated with higher fidelity. Higher fidelity to content was associated with the trial primary outcome of family caregiver report of patient wishes being discussed and met.

Conclusions Fidelity to content, but not quality, of the ACP intervention is strong. Communication skills training is critical for ACP interventionists. Adherence was higher with older patients and religious carers, factors that may influence acceptance of death and readiness to undertake ACP, making the discussion easier.

Trial registration number ACTRN12613001288718.

  • Intervention fidelity
  • audit
  • advance care planning
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Footnotes

  • Contributors LV contributed to the conceptualisation of this analysis, performed the fidelity coding and prepared the first draft of the paper. PNB contributed to the conceptualisation of this analysis and prepared the second draft of the paper. DL performed the fidelity coding and reviewed and commented on paper drafts. SBJ, JC and KMD contributed to the conceptualisation of this analysis and commented on paper drafts. MB contributed to the conceptualisation of this analysis, performed the statistical analyses and commented on paper drafts. MT led the project team, contributed to the conceptualisation of this analysis and commented on paper drafts.

  • Funding This study was funded by a grant from the Australian National Health and Medical Research Council (grant no: 1050596).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for the main study was received from the Sydney Local Health District (RPA Zone) Human Research Ethical Committee, (Protocol number X13-0064).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.

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