Main findings of the study
This study shows that an ACP document for palliative patients discharged from hospital, initiated by the clinical healthcare team treating the patient, is feasible. Upon its introduction, clinical nursing staff and medical doctors at the sites of introduction were instructed on the purpose and use of the ACP document. However, because of clinical rotations, the staff working with the document changed over time. Nonetheless, for each consecutive 6-month period from its introduction, the number of ACP documents that was filled out increased. Although no figures are known regarding the number of patients discharged with a terminal care indication at hospital II, this number remained stable at hospital I, showing the uptake of the ACP conversations and documentation in practice. Whilst initially not all eligible patients received an ACP document, throughout the study period, this portion kept increasing. Moreover, although the original indication for initiating ACP conversations and documentation was hospital discharge with a terminal care indication, throughout the study period, ACP documents were increasingly given to palliative patients with a longer life expectancy. This, too, demonstrates the uptake of ACP conversations and discussions in this setting.
The ACP document used was originally introduced in a study for GPs to timely identify palliative patients in their practice and initiate advance care planning [
30]. Only half the participating GPs actually identified palliative patients as such, and these in turn represented only a fraction of the patients that had died expectedly during the study period. However, a post hoc analysis carried out by Thoonsen et al. of the GP palliative patient identification study they conducted, suggested that patients that had been identified had fewer hospital admissions, and died at home more frequently, suggesting a beneficial effect of ACP conversations and documentation. Because the majority of palliative patients are treated for their condition at a hospital, marking the palliative phase and concurrently initiating ACP conversations and documentation at the hospital, in concertation with the patient’s GP could lead to an increase in ACP. This, in turn, could lead to a better QoL for palliative patients towards the end of life. This is, however, conditional on the feasibility of hospital-initiated ACP by clinical healthcare staff.
Although several studies have shown the feasibility of ACP by trained and skilled facilitators, [
22‐
25,
31] they are not as intricately aware of a patient’s specific situation and medical condition as the clinical healthcare team treating a patient. Many barriers to initiating ACP for clinicians have been identified [
31,
32]. Contrastingly, this study shows that it is feasible for a patient’s clinical healthcare team to initiate ACP conversations and documentation. In this way, advance care planning becomes an integral part of patient care, and can be tailored to a patient’s specific situation and medical condition. This will allow for better coordination of palliative care because the ACP document functions as an additional, up-to-date, on-site handover document for all healthcare professionals involved with a patient.
From a qualitative perspective, hospital-initiated ACP documentation is feasible as well. Compared to a study assessing ACP documentation amongst internal medicine residents at two major UK academic teaching centres, twice as many health care proxies were established, and CPR decisions were also documented more frequently, in 91% versus 70% of cases [
33]. On the other hand, fewer anticipated problems were documented in this study than patients are known to encounter towards the end of life [
34,
35]. One study reported fewer problems towards the end-of-life for the hospital inpatient subgroup (mean 2.7 problems) than were anticipated in the current study. However, reported problems in that study were exclusively physical in nature, suggesting a possible bias due to under recognition of problems in the other domains [
2].
In the current study, far fewer non-physical problems were documented than physical ones. This was particularly the case in hospitals I and II, where non-palliative care trained staff was responsible for ACP conversations and documentation. SPC nurses initiating ACP at hospital III seemed better equipped to identify non-physical problems. Likely, the importance and relevance of non-physical problems is not recognised by non-palliative care healthcare professionals, due to a lack of experience and training. Educating clinical healthcare providers could increase awareness and lead to a better recognition and treatment of these problems.
The majority of the ACP documents included in this cohort analysis were given to patients suffering from cancer. Of course, implementation took place at oncology departments in two of the three hospitals (hospitals I and II). However, it also reflects the fact that cancer is a common cause of death and has a relatively clear-cut course of decline and deterioration compared with for instance advanced chronic organ failure or dementia [
36,
37]. In a survey among GPs, they report finding it more difficult to have end-of-life discussions with patients with organ failure and other non-cancer terminal diseases than with terminal cancer [
19]. This may be true for hospital medical staff, too, but interestingly, despite the fact that ACP documentation was introduced exclusively at the medical oncology wards in hospitals I and II, advanced chronic organ failure was the diagnosis documented on 9 ACP documents originating from these hospitals, showing the uptake and spreading of ACP conversations and documentation in patients with non-cancer diagnoses.
The ACP document is not an end in itself. It is a dynamic document, onto which alterations can be made at any point by all clinical and non-clinical healthcare staff caring for a patient [
38]. In this way, transcendence of the hospital-to-home boundary and vice versa is achieved. GPs, in close collaboration with community district nurses, can continue where the patient’s clinical healthcare team left off, ensuring continuity of care with the palliative patient at its centre.
Strengths and weaknesses/ limitations
For this study, no information was gathered about patients’ or relatives’ views of the ACP document, nor did we obtain views of the GP and feedback about whether the document was used and if so, whether it was found helpful. It also remains to be researched whether this document will lead to fewer out-of-hours contacts, fewer unwanted hospital admissions and more deaths at the desired place of death.
Following the study period, the ACP document was evaluated by a working group of the regional palliative care network, based on how it was filled out by healthcare professionals. This led to some amendments to the document, for instance a change in wording: current and anticipated ‘problems’ were rephrased as ‘situation’, to be more inclusive. It was acknowledged that a complete picture of a situation comprises of more than problems alone.