Table 3

Elements of interaction between the doctor and the person or family member influencing engagement in ACP

Element of interaction Facilitator (F) or barrier (B)Illustrative quotes
Who initiates ACP(F) ACP initiated by the doctor‘Dr. should initiate the conversation…needs good communication skills.’ (P)
‘They have to ask.’ (FM)
(B) The doctor doesn't ask or encourage the conversation‘Sometimes I tried to talk to my doctor about things and she ignores me.’ (P)
‘If they ask…otherwise we don't say anything.’ (FM)
Amount of time for interaction between doctor and patient/family(F) Allowing time for ACP or the decision-making process‘It isn't difficult if the MD's would be more available and take some time to talk to us.’ (FM)
‘Give more time to make the decision.’ (FM)
(B) Doctors who don't appear to make time for ACP‘They don't have the time to listen. If they start talking about it they say I have to go…another patient…makes it unpleasant.’ (P)
‘Dr. needs to spend more time…spend time and listen.’ (FM)
‘No time set aside for this, doctors don't ask me about my wishes…doctors focus on other problems during a clinic or office visit.’ (P)
Location (both geographical and treatment context) of the interaction(F) Information upfront before the crisis in a private place is most helpful‘Need more information at the outset…discussion in the ER was hard.’ (P)
‘Dr. needs to bring it up when the patient is well.’ (P)
‘Would want that conversation confidential, not in the hallway.’ (FM)
(B) Emergency room/health crisis makes conversations harder‘The way and time its asked is important. In a crisis like in ER, the patient does not understand the questions then.’ (P)
‘The ER is not the time to ask family's and patients. It is a very stressful time’ (FM)
Relationship with doctor(F) Relationship with doctor is central to feeling supported in the conversation‘My doctor is religious like me…we sometimes have a prayer together.’ (P)
‘I have a good relationship with my GP, can talk about anything.’ (P)
(B) Not having a good relationship negatively impacts the interaction‘I don't have faith in my doctor taking care of an older person… she is not interested in my problems. Doctors don't ask me about my wishes.’ (P)
‘Feels doctor sees him as a number and not a person.’ (FM)
Qualities of communication(F) The doctor communicates with compassion, honesty and respect‘Compassion, mutual sincerity, empathy and time needed.’ (P)
‘Gentle but honest.’ (P)
‘Openness, we are on a learning curve.’ (FM)
‘If they would actually tell my Mom about her life expectancy, prognosis and treatment.’ (FM)
‘I like a doctor I can talk to that will listen to another person's views, that will talk to me with good bedside manner, some don't feel comfortable talking about it.’(P)
(B) A blunt, non-sensitive, closed approach with little time to respond‘Dr. needs to be more honest about the prognosis.’ (P)
‘Need more deep active listening rather than the one off approach.’ (P)
‘He was very blunt and I had to make a decision with little opportunity to discuss.’ (FM)
Ease of comprehension of information provided by doctor(F) Information is provided in a way that is easy to understand‘More understanding, in words that are easy to understand.’(P)
‘I want in plain words how long he has to live.’ (FM)
(B) Information is presented in a way that is difficult to understand‘Doctors don't use layman terms and don't explain options—drawbacks and benefits of the options.’ (FM)
‘No clarity. They didn't explain it all. Every time I come in, it is the same thing. I have been in the hospital 3 times in the last year.’ (P)
‘The way that the doctor asked about CPR was very confusing. I was not sure what she was asking. She [patient] does not want any of that [CPR, breathing machines] so I need to make sure they understand.’ (FM)
  • ACP, advance care planning; CPR, cardiopulmonary resuscitation;FM, family; GP, general practitioner; P, patient