Table 3.

Description of the components within a complex intervention to support the initiation of ACP in general practice

Components of a complex intervention to support the initiation of ACP in general practice (evidence based key feature described in Table 2)
Component 1: A training program for GPs (A)
Content of the component to overcome the barriers and enhance the facilitators: • Prior to the training, participants will receive reading materials to ensure baseline knowledge on ACP and the relevant law and to limit the time of the training • The training consists of information provision, case studies addressing the identified barriers to initiating ACP, facilitated group discussion and video demonstration of how to conduct ACP discussions and how to incorporate the initiation of ACP into standard consultations, and role play exercises with feedback from an expert instructor to practice the taught skills, which have been shown to be the best strategies to improve communication skills • GPs will learn about the key elements that should be addressed with patients, including exploring prognostic understanding and acceptance of diagnosis and providing patients with information about prognosis to the degree desired by the patient • Instructions are provided for GPs during the training to collect all information regarding the patient’s health status and treatment options, and to contact other health care professionals when necessary for this. • Training will be led by an expert instructor • After the training sessions, GPs will be able to practice their skills at home through e-simulation exercises with fictive patients	Barriers and facilitators that are adressed by the component: ➢ Lack of skills, knowledge about ACP and confidence to discussions ➢ Lack of awareness about the different elements of ACP ➢ Lack of knowledge about decision-making capacity legislation ➢ Recognizing the relevance of ACP ➢ Positive attitudes towards anticipating future scenarios and initiating ACP ➢ Patients’ denial and lack of awareness about prognosis ➢ Lack of adequate communication between GPs and the multiple clinicians involved in the patient’s care
Component 2: Establishing a register of patients eligible for ACP discussions (B)
Content of the component to overcome the barriers and enhance the facilitators: • Systematic and selective identification of patients at risk of deteriorating or dying will be done using a pragmatic three-step guide of triggers for when to initiate ACP • During the training, GPs will be taught how to identify eligible patients using these triggers and to set up an ACP register, which is a constantly updated list of patients for whom ACP should be initiated at upcoming appointments	Barriers and facilitators that are addressed by the component: ➢ Most GPs in the focus groups considered patients suffering from a life-limiting illness to be most eligible for initiating ACP with ➢ Difficulties with defining a key moment to initiate ACP ➢ Cancer patients are more easily involved in ACP as opposed to non-cancer patients (eg dementia, advanced organ failure, etc.)
Component 3: Educational booklet about ACP for patients (C)
Content of the component to overcome the barriers and enhance the facilitators: • The goal of an educational booklet is to provide patients with appropriate information on ACP in advance and to prepare them for a patient-centred discussion adapted to their individual information needs • This educational booklet includes a prompt list • Patients are encouraged to reflect on and clarify their wishes together with their relatives through discussion	Barriers and facilitators that are adressed by the component: ➢ Patients’ lack of understanding regarding ACP ➢ Patients are prepared to participate in ACP
Component 4: Patient-centred ACP discussions with the help of a conversation guide (D)
Content of the component to overcome the barriers and enhance the facilitators: • The conversation guide includes the following topics: understanding of prognosis, information preferences, prognostic information, patient’s previous experiences with ACP, patient goals and quality of life, fears, acceptable function, family involvement and contains examples of questions and communication tips	Barriers and facilitators that are adressed by the component: ➢ Lack of awareness about the different elements of ACP ➢ Varying conceptualisations of ACP among GPs
Component 5: A structured template for documenting the outcomes of the ACP discussions (E)
Content of the component to overcome the barriers and enhance the facilitators: • A structured template will provide the opportunity for recording patient preferences, values and goals of care • Instructions are provided for GPs during the training to communicate this document to other involved health care professionals (with patient permission). These instructions are also be included on the templates. • Patients are encouraged by the GP to make this document available for other care providers	Barriers and facilitators that are adressed by the component: ➢ Difficulties in sharing information across the health care system when patients are cared for by (multiple) specialists ➢ Uncertainty regarding the transferability of ACP information as there is no consistent standard for location