Author: Joanne Risk
Risk, Joanne, 2020 Advance care planning in general practice, Flinders University, College of Medicine and Public Health
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Background
Within the Australian primary health care policy framework, advance care planning (ACP) is intended to ensure quality care according to individual wishes at end of life. An advance care directive (ACD), sometimes called a ‘living will’ describes how an individual would prefer to be treated in the event of a loss of capacity to direct their own care. In Australia, policies and/or laws have been enacted across all States and Territories to support the uptake of ACP.
A 2014 national prevalence study identified uptake of ACP in Australia was approximately 14%, although another found rates as low as 3% in general practice patients. ACP is viewed as an important and emerging issue in the public health domain. A preliminary search of the literature highlighted the need for a system-wide and multi-faceted approach to ACP though specific guidance to support systematic general practice facilitation of ACP was lacking.
Aim
The aim of this dissertation was to achieve increased uptake of ACP in general practice. Four key components were a) co-designing a socio-ecologically engineered approach to ACP in general practice; b) determining the perceived feasibility of the ACP intervention in general practice; c) determining patient experiences of the ACP intervention in general practice; and d) determining the effectiveness of the approach in general practice.
Research design, methods, and analysis
A mixed methods quasi-experimental case study approach was used. An exemplar general practice was identified to co-design and implement a complex ACP intervention. The participating general practice became the single case study for the purposes of evaluating the approach. The intervention design was based on understanding barriers to ACP and enhancing enablers to improve ACP uptake by the practice’s patients aged over 75 years. Patients attending the practice for an annual 75+ health assessment were engaged in a 3-step intervention. Step 1 involved being asked about having an advance care directive (ACD). Step 2 involved the provision of an ACD booklet, and Step 3 was an invitation to participate in an ACP group information session. The intervention was evaluated over a 12-week period.
To measure and understand the impact of the complex ACP intervention, qualitative and quantitative data were collected across individual, interpersonal, provider and system levels within this case. Quantitative data analysis involved comparison of ACD prevalence between control and intervention groups. Before and after health literacy data were collected for the intervention group and process measures of implementation were assessed. Qualitative analysis involved thematic analysis of participant and provider interviews.
Findings
During the intervention evaluation period (12 weeks), 123 patients were involved in Step 1, 85 patients were involved in Step 2, and 19 patients consented to participate in Step 3. At the end of the evaluation period, patients who had attended the practice for a 75+ health assessment during the study period were 1.79 times [CI 1.1–2.9; p=0.012] more likely to have an advance care directive than those patients attending in the six months prior to the study period. Patients who participated in all three steps of the process had the highest uptake of ACD, with eight of 19 [42%] participants completing an ACD [p=0.012].
In total, 17 interviews were conducted with eight randomly selected participants and nine health care providers. Thematic analysis of interview data confirmed the general acceptability of the intervention approach to ACP in general practice with endorsement from patients and providers about the role of the general practice in systematically engaging patients in ACP discussions. Key themes arising included the important role of provider as initiator, and the concept of shared wisdom and social support enabling discussion about things we don’t talk about for participants.
Conclusion
The study demonstrates that a 3-step ACP intervention in general practice is a feasible and effective way to increase uptake of ACP in patients aged over 75 years. The co-design approach and subsequent guidance contribute to new evidence supporting future implementation of the approach in general practices interested in increasing uptake of ACD by their patient population.
Keywords: advance care planning, advance care directives; general practice, socio-ecological perspective, complex intervention, group intervention
Subject: Public Health thesis
Thesis type: Professional Doctorate
Completed: 2020
School: College of Medicine and Public Health
Supervisor: Professor Paul Ward