Group-based educational intervention for advance care planning in primary care: a quasi-experimental study in Japan

Background: Older adults who have health conditions with good prognoses typically fall outside the scope of efforts encouraging advance care planning. We developed group and individual versions of an advance care planning program for use in primary care. Methods: We conducted a quasi-experimental trial in a rural family clinic in Japan. Medically stable patients aged ≥65 years were invited to watch an educational video on advance care planning, followed by an individual (n=46) or group-based (n=63) discussion. Advance directive completion was tracked over four months. Participants completed baseline and follow-up questionnaires and reported occurrence of family discussions about advance care planning and attitudes toward advance care planning. Group discussions were recorded and thematically analyzed to identify barriers and facilitators to engaging in advance care planning. Results: Advance directive completion rates were high for both intervention versions but did not significantly differ between arms (85.7% vs. 80.4%, p=0.45). Only one-fifth of patients in both arms discussed advance care planning with their family after the intervention (20.7% and 21.7%, p=0.89). Patients in the group arm rated their experience slightly higher than those in the individual arm (4.2 and 3.9 out of 5, p=0.023). Qualitative analysis of group discussions revealed that patients were affected by their perceptions of societal norms that prioritize family consensus over patient autonomy; however, these perceptions influenced advance care planning behaviors in inconsistent ways. Conclusions: Group-based advance care planning intervention among medically stable older patients is as effective as an individually-focused discussion in promoting advance directive completion. Future research is needed on ways to enhance patients’ ability to discuss advance care planning with their family members.