Health professionals’ perspectives on the provision of advance care planning to adult patients who deteriorate in hospital: A mixed methods phenomenological research study

Wendy Kinton

doi:10.25907/00719

Background: Advance care planning (ACP) is a multi-faceted process of determining future health care needs for a time when a person may be unable to speak for themselves due to illness or impaired cognition. ACP could have multiple benefits for patients, their families, health professionals and health services. It may guide end-of-life decision-making and ensure a patient’s best interests are respected when treatment is provided. For health professionals, ACP may assist with writing clinical plans, and decrease the moral burden relating to making difficult care decisions. An ACP document may prevent the provision of resource-intensive or non-beneficial treatments at the end of life that may result in moral distress for a health professional involved in the care of the dying person. Aim: The aim of this research project was to investigate the provision of ACP, particularly in the context of adult patients who experienced clinical deterioration in the acute hospital setting and required review by a Rapid Response Team (RRT). A better understanding of the prevalence of ACP documents in patients’ health records, the extent to which health professionals perceive themselves to be confident, knowledgeable, and skilled in providing ACP, and perceived roles, responsibilities, and scope of practice was also sought. Design: This health services research project was conducted using Mixed Methods Phenomenological Research (MMPR). This flexible approach allowed combining quantitative and qualitative research methods to provide a rich understanding of the provision of ACP. Two systematic literature reviews were conducted to allow a comprehensive understanding of the literature and identify research gaps. The first related to the provision of ACP in the context of clinical deterioration, and the second presented outcomes of continuing education programs for health professionals. Three separate studies were then undertaken. The first was a retrospective chart audit to evaluate the prevalence of ACP documents in patients’ health records. The second was a questionnaire study exploring health professionals’ perspectives of providing ACP, and the third was an interview study investigating health professionals’ perceived roles and responsibilities in providing ACP. Setting: This research was conducted within the Sunshine Coast Hospital and Health Service (SCHHS), a large regional health service in Queensland, Australia. Participants: Participants were health professionals from medical, nursing, and allied health workforce groups across the health service. Results: The Role Identity Equilibrium Process (RIEP) was proposed as a theoretical model for conceptualising how ACP is provided in the hospital setting in the context of the deteriorating patient. The model proved useful for collecting, discussing, and reporting the results of the three studies undertaken. This research found that the prevalence of ACP documents in the health records was low, with only 7% of patient records containing a formal ACP document. Discussions with a patient or their substitute decision maker about care and treatment wishes were documented in just under half of the records (48.3%). Patients’ wishes for care tended to be documented on an Acute Resuscitation Plan. The health professional participants did not share a common understanding of the end-of-life time frame, nor the full extent of activities considered part of ACP. Apart from doctors, other health professionals did not identify a legitimate role in discussing ACP. Health professionals’ self-perceived confidence, knowledge, and skills in discussing ACP was low, which contributed to their lack of an individual or collective professional identity, and abdication of responsibility for conducting ACP. Morally challenging incidents were discussed by some nurses where the lack of ACP and resuscitation planning meant that a patient may receive care, they believed would be inappropriate. These disequilibrating events, whilst distressing may have some value if introduced in a hypothetical education scenario for strengthening role identity and driving role expansion. Conclusions: This research project contributed to current knowledge about the provision of ACP, identified contributions and recommendations for methodology, theory, clinical practice and identified areas for future research. It has offered insights into how ACP is provided in one Australian context. A better understanding of ACP provision from the perspective of health professionals, and the influence of personal and professional experiences, cultural and workplace practices within the SCHHS may inform better ACP processes and person-centred care at the end of life.

Health professionals’ perspectives on the provision of advance care planning to adult patients who deteriorate in hospital: A mixed methods phenomenological research study

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