Implementation of An Advance Care Planning Intervention in Dialysis Clinics

Sharing Patient's Illness Representations to Increase Trust (SPIRIT) is an evidence-based advance care planning intervention targeting dialysis patients and their surrogate decision-makers. To address SPIRIT's implementation potential, we report on a process evaluation in our recently completed 5-state cluster-randomized trial.

A descriptive study of implementation within a randomized clinical trial.

231 patient-surrogate dyads and 60 dialysis care providers in the 22 active intervention clinics.

Status as a patient/surrogate, care provider, or care provider "champion" who all were randomized to clinics implementing the SPIRIT implementation.

(1) Intervention reach (eg, number of dyads who received SPIRIT relative to each clinic's census); (2) fidelity (eg, champions' self-evaluation checklists, patient and surrogate surveys); (3) sustainability (patient, surrogate, and dialysis care provider acceptability surveys); and (4) context (eg, clinic characteristics).

Of the 2 SPIRIT sessions, 191 participants (82.7%) completed session 1 and 146 (76.4% of 191) completed the optional session 2. Of the 40 champions, 34 completed at least 1 SPIRIT session 1. Champions reported that all 6 intervention steps were completed in 98% to 100% of their sessions. The median duration of session 1 and session 2 were 60 minutes and 15 minutes, respectively. The acceptability surveys suggested a high level of acceptance by patients, surrogates, and providers. Champions reported the main benefits of SPIRIT to be enhanced learning; communication; and improved relationships for patients, surrogates, and providers. The challenges champions reported were scheduling a time that worked for the patient, surrogate, and champion; feeling torn between SPIRIT and other clinical demands; and the emotional burden on the champions themselves.

The lack of data on actual continued use of SPIRIT and low provider participation in acceptability survey.

This study suggests that SPIRIT was delivered with high fidelity and was experienced positively by stakeholders. However, challenges such as staffing and emotional burden required clinic-level support and warrant future studies testing implementation strategies to address these barriers.