The national iCAN-ACP study was developed to test ways to improve advance care planning (ACP) conversations between patients, families and health professionals. The aim was to narrow the gap between the care that elderly Canadians living with frailty want and the care that they receive.
The study had four project teams focusing on different settings in healthcare – Primary Care, Hospital Sector, Long-term Care and the Diversity Access Team.
Primary Care team results
BCCPC research staff participated as members of the Primary Care team, which focused on using tools in various family practice settings to increase access, uptake, and impact of advance care planning in BC, Ontario and Alberta. The team’s overarching aim was to support family physicians and allied health practitioners in primary care practice to have early and ongoing ACP conversations with their patients. This included developing and evaluating a care pathway in Alberta and BC family practices which trained family physicians to have serious illness conversations, with research staff developing patient and family tools to introduce advance care planning and have preliminary conversations.
The findings reinforce emerging evidence that training and structured approaches for ACP conversations help health care providers to have more (and better) conversations, and, as an outcome, better understand their patients’ values and wishes. For patients, ACP education and conversations increased their engagement and sense of agency.
A secondary study in BC also surveyed family physicians regarding willingness to partner with community-based organizations to enhance patient and family readiness and engagement in ACP.
Key Findings
The key findings of the Primary Care team were:
• A ‘stepped’ care pathway that includes roles for physicians as well as clinic and support staff promotes a multidisciplinary approach to ACP and is effective.
• Education and training for primary care clinicians increased knowledge, comfort and confidence in having ACP conversations.
• Clear, standardized documentation, processes and toolkits can help overcome barriers and support good quality ACP conversations.
• Early involvement of the Substitute Decision Maker (SDM) is beneficial in conversations with the patient regarding wishes and preferences.
• There may be a role for partnership between primary care and community-based organizations to improve patient and SDM awareness and engagement in ACP.
The recommendations that flowed from the team’s work include calls for more research as well as recommendations to provide ACP and serious illness conversation education and training for family physicians and allied health professionals, and to integrate a stepped care pathway supported by ACP education for patients and families into routine primary care practice.
Visit iCanACP.ca for more information on the study, as well as the findings and recommendations from all of the project teams, or click here for information on the primary care team’ results in particular. Or check out the iCanACP news page for the latest updates.
Jump to study results
The iCAN ACP study was a 3 year pan-Canadian study which included:
• 32 investigators from multiple disciplines at 16 Canadian universities
• 5 patient advisors
• 5 international collaborators
• 42 partner organizations
Study results
- Following SIC Training and introduction to tools, clinicians described improved confidence to integrate ACP into practice.
- The stepped care pathway is well-suited to a multidisciplinary approach to ACP:
- The role of the physician was vital in identifying and screening patients, reviewing documentation, and finalizing patient values and wishes.
- The role of clinic and support staff, who recruited patients into the care pathway and provided education and support, was also critical to the success of the pathway.
- Clear, standardized documentation was critical for communication between clinicians about the care pathway but also to capture values and goals in the patient medical chart.
- Clinicians cited the early involvement of the substitute decision maker (SDM) in the ACP process as beneficial.
- Physicians reported that conversations were more streamlined because patients were better prepared to discuss goals and wishes. Documentation was facilitated with interprofessional cooperation and role clarity.
- The majority of patients reported feeling more heard and understood by their physician after the conversations.
Conclusions
- The care pathway was effective at increasing patient ACP engagement and improving patient experience; and a structured process, with documentation as a key component, was helpful for clinicians, compared to their previous unstructured approach.
- A toolkit outlining structured processes of the stepped care pathway can overcome ACP barriers in primary care.
Recommendations
- Provide ACP/Serious Illness Conversation education and training for family physicians and allied health professionals
- Integrate a stepped care pathway with ACP tools into routine primary care practice
- Conduct more research about how to evaluate the above to ensure sustainability in practice
- Conduct more research about the role of the SDM and SDM-specific ACP tools
- Consider clinician recommendations for future research on this topic: care pathway ‘lite’ for some patients or practices; the potential for virtual ACP in the context of COVID-19; the role of allied health; the importance of serious illness conversation training and ACP tool use.
