What are the barriers and facilitators to advance care planning with older people in long-term care facilities? A qualitative study

Abstract

Aim: To explore the views and preferences for advance care planning from the perspectives of residents, family members and healthcare professionals in long-term care facilities.

Design: A qualitative descriptive design.

Methods: We conducted semi-structured interviews with 12 residents of long-term care facilities, 10 family members and 14 healthcare professionals. Data were analysed using reflexive thematic analysis. The social ecological model was used to develop implementation recommendations.

Results: We constructed a conceptual model of barriers and facilitators to advance care planning in long-term care facilities, drawing upon four dominant themes from the qualitative analysis: (1) The absence of discourse on end-of-life care: a lack of cultural climate to talk about death, the unspoken agreement to avoid conversations about death, and poor awareness of palliative care may hinder advance care planning initiation; (2) Relational decision-making process is a dual factor affecting advance care planning engagement; (3) Low trust and 'unsafe' cultures: a lack of honest information sharing, risks of violating social expectations and damaging social relationships, and risks of legal consequences may hinder willingness to engage in advance care planning; (4) Meeting and respecting residents' psychosocial needs: these can be addressed by readiness assessment, initiating advance care planning in an informal and equal manner and involving social workers.

Conclusion: Our findings show that residents' voices were not being heard. It is necessary to identify residents' spontaneous conversation triggers, articulate the value of advance care planning in light of the family's values and preferences, and respect residents' psychosocial needs to promote advance care planning in long-term care facilities. Advance care planning may alleviate the decision-making burden of offspring in nuclear families.

Implications for clinical practice: The evidence-based recommendations in this study will inform the implementation of context-specific advance care planning in Asia-Pacific regions.

Patient and public contribution: Patients and caregivers contributed to the interview pilot and data collection.

Keywords: advance care planning; decision-making; end-of-life care; long-term care facilities; older people; palliative care.