Barriers and Facilitators to the Implementation of Advance Care Planning: A Qualitative Study at National and Organizational Levels

Abstract

Background

Aging population, enhanced medical opportunities, increased costs and emphasis on patient participation make advance care planning (ACP) important and it provides an evidence-based framework to ensure patient autonomy in future healthcare decisions. Despite the extensive international research literature supporting ACP, implementation seems challenging. Implementing complex interventions like ACP probably requires a system-wide approach. However, there is scarce research on the barriers and facilitators to ACP implementation as perceived at national and organizational levels.

Aim

To explore the barriers and facilitators affecting ACP implementation as perceived at national and organizational levels.

Methods

Fifteen in-depth individual interviews were conducted with stakeholders at national and organizational levels. A semi-structured interview guide was used, targeting overarching conditions and framework factors that could have an impact. Data was analysed using thematic analysis.

Results

Barriers to ACP implementation described by participants included: Lack of prioritization of ACP at all levels; paradigms and culture of healthcare delivery, personal barriers and attitudes, and lack of competence; lack of collaboration and documentation between levels of healthcare; and lack of systems, routines, time and resources within healthcare services. Facilitators included: Cultural change; support in priority setting; national guideline and incentives; management commitment and support; systems, routines and local implementation efforts; ACP capacity building, implementation competence, and ethical reflection; dissemination of the benefits of ACP, including public education; and better collaboration and communication between levels of healthcare.

Conclusion

There appear to be significant barriers and facilitators to ACP implementation as perceived at the national and organizational levels of healthcare. Although ACP implementation appears to require a combination of top-down and bottom-up initiatives, national and organizational barriers and facilitators seem important in setting priorities in clinical practice, with an emphasis on financial incentives. An overarching cultural change of healthcare delivery that supports interventions such as ACP appears to be critical for improved implementation.