Optimizing Approaches in Advance Care Planning in Dementia as Perceived by General Practitioners.

Abstract

Feasible, person-centered advance care planning (ACP) approaches for persons with dementia and their care partners are needed, and the optimal approach may differ depending on the situation. Two contrasting approaches involve a highly scripted medical order-setting approach to decide on specific treatments in advance, vs a flexible goal-eliciting, more psychosocially-oriented coping-based approach. To distinguish situations in which either approach is preferred in dementia from the perspective of general practitioners. We interviewed 13 practitioners participating in the CONT-END program in the Netherlands. Seven were trained in the order-setting approach and six in the goal-eliciting approach for an ACP trial. Twelve other practitioners participated in a video vignette study showing the two approaches, and we triangulated findings. Inductive qualitative content analyses of interviews aimed at elucidating for whom and when an approach was preferred. Four attributes distinguished situations in which either approach is preferred: understanding, trust, readiness, and momentum. For the order-setting approach, understanding, trust, and readiness of person and care partner were prerequisites for momentum (time right to express preferences), when not triggered for urgent medical reasons. In contrast, the goal-eliciting approach would help understand the person, foster trust, and create readiness from a first conversation. Without a clear trigger, however, momentum would need to be created. Skill in employing various approaches to ACP conversations, each with specific benefits, could help tailor ACP to the individual and their situation. Further theoretical and empirical research, including in other populations and settings, may inform person-centered ACP.