Impact of nurse-led advance care planning in a primary care setting

We aimed to evaluate patient and clinician experiences of advance care planning (ACP) conversations facilitated by an ACP nurse coordinator (ACP-NC).

We used a sequential mixed-methods approach that included a patient survey, patient interviews, and clinician interviews at a family medicine clinic. Patients were invited into the study if they had reached a stable point in their ACP decision-making conversations with the ACP-NC or PCP (i.e. their goals and preferences were considered settled at the time) and were not imminently dying. Invitations to complete a survey were sent within 2 weeks of patients completing their ACP conversations. Patient interviewees were purposefully selected to vary on key attributes such as age, gender, and number of ACP conversations. An iterative sampling strategy was used for both patient and clinician interviews.

Ninety-three patients completed the survey, and 10 patients were interviewed. Six clinicians were interviewed. Sixty percent of patient respondents reported being very comfortable having ACP conversations. At the time of the survey, 79% had completed or revised their existing advance directive. The professional groups that patients most preferred to engage with, regarding ACP, were their primary care provider (87%), ACP-NC (70%), and palliative care specialist (61%). Patient interviews indicated that participants appreciated being referred to the ACP-NC within the clinic, describing her as a motivator and generous with her time, which facilitated thoughtful discussion of preferences and wishes. Clinician interviews identified limited time as a key barrier to conducting ACP conversations and saw a dedicated ACP-NC as a major benefit to allow patients to spend more time having these important conversations.

Patients were open to engaging in ACP discussions. Integrating an ACP-NC within primary care teams may represent an acceptable and effective approach to promote the early initiation of ACP in primary care settings.