When do Physicians and Nurses Start Communication about Advance Care Planning? A Qualitative Study at an Acute Care Hosp

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When do Physicians and Nurses Start Communication about Advance Care Planning? A Qualitative Study at an Acute Care Hospital in Japan Mari Tsuruwaka 1 & Yoshiko Ikeguchi 2 & Megumi Nakamura 3 Received: 12 August 2019 / Revised: 24 June 2020 / Accepted: 2 July 2020 / Published online: 13 July 2020 # The Author(s) 2020

Abstract Although advance care planning (ACP) can lead to more patient-centered care, the communication around it can be challenging in acute care hospitals, where saving a life or shortening hospitalization is important priorities. Our qualitative study in an acute care hospital in Japan revealed when specifically physicians and nurses start communication to facilitate ACP. Seven physicians and 19 nurses responded to an interview request, explaining when ACP communication was initiated with 32 patients aged 65 or older. Our qualitative approach employed descriptive analysis to identify major themes, which included “initiation by patients” and “initiation by healthcare professionals.” In the latter case, seven specific triggers were identified: (1) when the patients’ medical condition changed in terms of symptom relief, (2) when the patients’ medical condition changed in terms of prognostic prediction, (3) when serious events occurred, (4) when a choice of treatment was presented, (5) when the location for end-of-life care was chosen, (6) when the patients’ cognitive function deteriorated, and (7) when serious events settled down. Within this group of healthcare professionals, physicians were more focused on changes in their patients’ medical condition, whereas nurses focused more on their patients’ desire for a long-term perspective. Nurses encouraged patients to consider ACP themselves, which developed into an approach to respect patients’ autonomy. In acute care hospitals, it appeared to be desirable to have an early discussion where patients could understand the significance ACP, which would matter even after their discharge from the hospital. Keywords Advance care planning . Advance care planning communication . Acute care

hospital . Japan . End of life care

* Mari Tsuruwaka [email protected] Extended author information available on the last page of the article

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Asian Bioethics Review (2020) 12:289–305

Background Advance care planning (ACP) has been conceptualized on the ethical basis of respect for patients’ autonomy (Johnstone and Kanitsaki 2009; Fahner et al. 2018) and is expected to improve the quality of medical treatment and care and realize the goal of patient-centered care. It has been defined as the process through which patients discuss their wishes and preferences regarding their medical treatment, end of life care, and often also the location of those, with their family, those dear to them, and medical staff, in advance of a potential decline in mental capacity. ACP communication is particularly important in acute care hospitals, where several challenges have been identified, including the following five. First, lifesaving medical care is often prioritized over