Table 3 Representative Quotes: Social Worker and Nephrologist Responses to Open-Ended Survey Questions

 Intervention Characteristics

Put[s] the patient in control [of the discussion], not like rounds (SW)

[Provided] an opportunity to talk with family and patient together (SW)

Fostered trust between the patient and the team (SW)

 Process

Having patient’s pre-survey ahead of time

Intervention guideline (SW)

E-mail reminders about what to cover (SW)

Having privacy of an isolation room if ACP discussion took place while patient on dialysis (SW)

 Intervention Characteristics

SW must be [physically] present at ACP discussion [not on phone] (SW)

 Process

Families and patients needed more preparation for ACP discussion (SW)

Doctor and social worker need to meet before ACP discussion to coordinate roles (SW)

Too much time between recruitment and intervention (SW)

Not good to have ACP discussion while patient on dialysis (SW)

 Inner Setting

Hard to schedule time when all can be there (SW)

Recording intervention session felt awkward (SW)

 Outer Setting

Some patients not ready to discuss ACP (SW)

Difficulty conducting discussion with patients with limited English proficiency (SW)

 Personal Characteristics

None – the intervention is not necessary

 Process

Start ACP either as soon as a patient begins or just prior to beginning hemodialysis

Have more frequent follow-up discussions after initial discussion (SW)

Meet patients at their homes for ACP discussions (MD)

Conduct ACP discussions during rounds (MD)

Have hospice worker or hospice handout at ACP discussion (SW)

Train all dialysis staff to talk about ACP (MD)

Make training inter-professional (SW)

 Inner Setting

Make it a policy to hold ACP discussions annually (SW)

 Outer Setting

Pay SW more for the additional work (MD)

 Personal Characteristics

None – the intervention is not necessary (SW)