Advance Care Planning Conversations in Primary Care: a Quality Improvement Project Using the Serious Illness Care Program

Background: Advance care planning (ACP) conversations are associated with improved end-of-life healthcare outcomes and patients want to engage in ACP with their healthcare providers. Despite this, ACP conversations rarely occur in primary care settings. Therefore, the objective of this study was to implement ACP through adapted Serious Illness Care Program (SICP) training sessions, and to understand primary care provider perceptions of implementing ACP into practice. Methods: We conducted a quality improvement project guided by the Normalization Process Theory (NPT). NPT is an explanatory model the delineates the processes by which organizations implement and integrate new work. The project was implemented in an interprofessional academic family medicine group in Hamilton, Ontario, Canada. Primary care providers (PCP), consisting of physicians, family medicine residents, and allied health care providers, completed Pre- and post-SICP training self-assessments, NoMAD surveys, and structured interviews. Results: 30 PCPs participated in SICP training and completed self-assessments, 14 completed NoMAD surveys, and 7 were interviewed. Training self-assessments reported improvements in ACP confidence and skills. NoMAD surveys reported mixed opinions towards ACP implementation into primary care, raising concerns with their colleagues’ abilities to conduct ACP and their patients’ abilities to participate in ACP conversations. Interviews identified barriers to successful implementation including busy clinical schedules, patient preparedness, and provider discomfort or lack of confidence in having ACP conversations. Allied health identified discussing prognosis, scope of practice limitations and identification of appropriate patients as barriers. Conclusions: Our findings complement existing literature regarding high PCP confidence and willingness to conduct ACP, but low participation which may be attributed to logistical challenges. Our findings identified areas of the SICP that were more difficult to implement (i.e., prognostication). Future iterations will require a more systematic process to support the implementation of ACP into regular practice and to address knowledge gaps identified with targeted training.