Advance care planning in German nursing homes from the perspective of the facilitators: A focus group study

Since 2018, German nursing homes have been able to reimburse advance care planning (ACP) at the expense of statutory health insurance. ACP is a consultation for end-of-life care in which care preferences can be documented. The consultation is conducted by facilitators, who have completed the required training. However, limited research exists on how the ACP consultation processes are realized. Hence, this focus group study, as a part of the "Gut-Leben" research project, investigated its implementation.

Twenty-four ACP facilitators participated in four semi-structured focus groups conducted between July and September 2023. The first three focus groups were held in person with participants from Lower Saxony and Bremen, and the fourth was conducted digitally to include facilitators from other federal states in Germany. The interview guide was developed with the project's practice advisory board in advance. The analysis was performed using deductive-inductive content analysis based on Kuckartz and Rädiker.

The facilitators' average age was 51.7 years (range 30-70), with 75.0% being female (n = 18). Facilitators typically reached out to residents proactively with the support of the nursing staff, who acted as intermediaries and helped to establish contact between the facilitators and the residents and/or relatives. Residents and relatives rarely approached the facilitators. The ACP consultation process varied in length and frequency, beginning with an initial information meeting and followed by further meetings if needed. Update meetings could be scheduled at any time, particularly in response to changes in residents' preferences or health status, but were implemented frequently. The consultation process and the documents created during the consultation, above all the living wills, were described as very complex, especially for cognitively impaired people, which is why standardized and simplified documents are desirable.

The results indicate that ACP is highly individualized, varying by resident. However, there is a rough standardized procedure for the process, which, like the documents, could be very complex. ACP must be more widely promoted to raise awareness, reduce inhibitions, and simplify the initiation of consultation processes. Besides, ACP must also be integrated into the structure of nursing homes as a fixed procedure.