Barriers and facilitators in implementing advance care planning for older patients acutely admitted to geriatric hospital units: A nested qualitative study

Linn Brøderud^1*Maria Romøren^1,2Karin Berg Hermansen³Trygve Johannes Lereim Sævareid^1,4Lisbeth Thoresen⁵Reidar Pedersen¹

• ¹Universitetet i Oslo Senter for Medisinsk Etikk, Oslo, Norway
• ²Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo,, Oslo, Norway
• ³Department of Health Sciences, Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway
• ⁴Universitetet i Agder Institutt for helse- og sykepleievitenskap, Kristiansand, Norway
• ⁵Department of Public Health and Interdisciplinary Health Sciences, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, Oslo, Norway

Background: Appropriate communication with patients is increasingly crucial in a growing elderly population to prevent both over-and under-treatment. Advance care planning (ACP) is recognized as a valuable communication process for patients, their relatives and healthcare professionals that facilitates future care and medical decision-making. Despite its importance, the uptake remains low, particularly among frail, older patients in hospitals. Methods: This qualitative substudy is nested within a cluster randomized controlled trial. Data collection involved eight semi-structured interviews conducted in acute geriatric units receiving our implementation support program, along with informal data from interactions with the units during the implementation process. The aim was to explore healthcare professionals' perspectives on the barriers and facilitators to ACP implementation and their experiences with the implementation support program. A semi-structured interview guide was used. The data was analyzed using content analysis. Results: Factors influencing ACP implementation were identified at three levels: a) the organizational level, b) the clinical level, and c) the national level. Participants recognized the critical role of timing, context, and patients' capacity. However, there was meaningful opportunities for ACP conversations in acute geriatric units. Overall, the experiences underscored the complex interplay of individual motivation and interest, organizational support, prioritization, available time and resources, and systemic factors that influence the integration of ACP into clinical practice, as well as the fact that research can act as both a barrier and a facilitator in implementation efforts. Discussion: This study illustrates the significant challenges in implementing ACP in acute hospital care. Despite a generally positive perception of ACP, its implementation was hindered by barriers such as overwhelming workload, production-oriented healthcare, the biomedical model, and lack of prioritization. These factors creates a cycle where short-term demands overshadow preventive and patient-centered interventions, limiting their perceived and documented benefits. Breaking this cycle will likely require targeted investment in the implementation of complex interventions. Trial registration: ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.