Advance Care Planning and Goals of Care Discussions in Long-Term Care: Results of a Survey of Clinician Barriers and of Power of Attorney (POA) Reports of Prior Discussions

Long-term care (LTC) is an important setting for communication about healthcare wishes near end of life. LTC residents may lack capacity to make treatment decisions. Hence, advance care planning (ACP) and goals of care (GOC) conversations between residents, substitute decision-makers (SDM) and healthcare providers are important. Overall, SDMs and clinicians agree ACP is important in LTC, yet there is a perception that it seldom occurs. To describe the clinician-reported barriers to GOC conversations and SDM-reported rates of ACP in the LTC setting. We used a modified Dillman approach to administer self-completed surveys at 35 LTC facilities in Southwestern Ontario. Clinician surveys asked physicians, nurses and allied health professionals (n=1282) to rate GOC barriers on a seven-point Likert scale (1=extremely unimportant; 7=extremely important). Paper surveys were sent to SDM, the Power of Attorney (POA) on file (n=2693). Rates of ACP were recorded as yes/no/unsure. Of the 563 clinicians willing to participate the response rate was 75% (n=422). Nurses comprised 77.5% of respondents. Mean clinician ratings of barriers were high (>5/7). Overall, clinicians identified patient-SDM factors, especially ‘POA difficulty in accepting a resident's prognosis', as top barriers. SDM response rate was 24.4%. SDMs (69%) reported that the resident had an ACP, 91% reported that the resident had named an SDM in writing, and 89% reported that the resident had shared the ACP with their SDM. Most SDMs reported that their loved one had engaged in ACP before entering LTC, most notably naming an SDM which is a requirement upon entering LTC. This suggests ACP preparedness, yet clinicians' highest-rated barriers relate to patient/POA factors. There is a need to better understand how to reduce barriers to communication about prior ACP to inform goals of care discussions that need to happen in the home.