TABLE 2.

Qualitative Themes Identified from Semi-Structured Interviews of Advanced Practice Providers

Theme	Subtheme	Illustrative Quotes
Clinical and professional benefits of ACP	Build trust and shared understanding	“I had a nice trail of ACP notes that I was able to file from pretty early on in my interactions with [the patient] and his family and [the ACP documentation] established my relationship with them and the conversations that we had … really laid a nice map. When I brought up that we really needed to shift goals of care or at least have a conversation about it, I had all those conversations and that documented…”
	Facilitates interprofessional collaboration	“I actually think it’s a combination…the [Attending and APP]…would be the best choices.”
	Reduces uncertainty	“I’ve seen unexpected…outcomes after surgeries…the ACP planning notes are really helpful to guide conversations with families in those situations.”
Barriers to APP involvement in ACP persist	Competing clinical demands	“Time…is a huge factor on how much time [APPs] can really spend with patients having these conversations when there’s already so much to cover about their surgery and what’s coming up for them in their hospital experience.”
	Variations in training and experience	“As part of my fellowship, there were these advanced communication classes with patients, which were exceedingly helpful. They make you do roleplaying, and stuff like that. So to have that be available for everyone [would be] helpful.”
	Unclear scope of work	“I think a lot of APPs don’t feel like it’s their place to have these conversations when it 100% is.”
Interventions to integrate APPs into ACP	Need for a surgeon champion	“Feeling like we have the permission to have these conversations from our attendings.”
	System-based support, standardized workflow, and improved education	“I think it would be helpful to have, like, a general kind of universal framework for how these discussions should happen…just having a plan makes people feel more comfortable about having the conversation to begin.”
	Enhanced patient preparedness	“Giving people some pre-discussion literature or something like that, and then when they come for their preop visit…we can have the discussion then. But [ACP is] definitely not something they’re prepared for. We would want them to be prepared for the discussion and not just to bring the discussion up.”