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Table 2 Key elements of the ACP-GP intervention

From: Facilitating advance care planning in the general practice setting for patients with a chronic, life-limiting illness: protocol for a phase-III cluster-randomized controlled trial and process evaluation of the ACP-GP intervention

1. GP training The GP training, which has been tested multiple times, is originally conceptualized as two interactive sessions of 3 h each, delivered to small groups of 6–8 GPs at a time within the university hospital setting or another location that is convenient for the participants. However, due to COVID-19 concerns, the content of the training has been translated to an online platform. The training is provided by a trainer experienced in primary care and communication.
Two interactive web sessions of approximately 2 h each will replace the live sessions. Preparatory activities such as fictional case examples with reflection questions will be available before the training begins. GPs will have access to background information portions through an e-learning module presented via the Ufora platform of the Universiteit Gent. This module will take no more than 60 min to review.
The first aim, improving ACP knowledge, will be addressed via the e-learning module. ACP communication skills will be practiced with video role-modeling exercises which are available on the e-learning module and will be further elaborated on during the web sessions. These web sessions will also include role-play exercises with model patients and interactive discussions with fellow GPs and the trainer.
During the training, GPs will receive an extensive conversation guide and an at-a-glance conversation flowchart. These can be used as preparation for and during ACP conversations with patients.
In the context of their continuous medical education, GPs will be able to obtain accreditation in ethics and economy by following the training. GPs in the control group will have the opportunity to follow the training after the conclusion of the study, so that both groups have access to this incentive.
After the training sessions, GPs will have the opportunity for check-in discussions with the trainers to ask questions and report issues.
2. ACP workbook for patients During the first home visit, the RA will give patients an ACP workbook that highlights the importance of ACP at different stages of health.
The workbook contains questions to stimulate reflection on topics such as quality of life and preferences for future care. The workbook is adjusted for health literacy and has been evaluated through cognitive interviewing with 6 patients who fulfill the inclusion criteria of the trial.
3. Patient-centered ACP discussion with conversation guide After the training, the GP will conduct a minimum of two ACP conversations in the patient’s home or in the GP office. If COVID-19 safety concerns prohibit the GP from speaking face-to-face with the patient, a telephone consultation or video-consult via an accredited electronic health record software package is also possible.
The first conversation takes place within 2 weeks after the GP has received the training; the second within a month after the first conversation.
The GP can use the conversation guide, which contains parallel topics to the patient workbook, to structure the conversation. First, the patient is invited to talk about the questions and topics they saw as most important. Then, if time permits, the conversation moves to the questions that have not yet been discussed
Patients can choose to have their SDM present at these conversations. If the patient has not yet identified an SDM, they will be encouraged to think about who might be a good fit for this role.
Other already-available documents, such as advance directive forms or patient guide materials such as the information booklet provided by the LevensEinde Informatie Forum (LEIF), may be used as the GP or patients see fit.
The ACP discussion is expected to last up to 60 min, but GPs are advised during the training to judge the optimal duration according to the openness and engagement of the patient.
4. Documentation of the ACP discussion The GP will fill out a template reflecting the outcomes of each ACP conversation. The template is based on the structure of the conversation guide. Here, the GP can freely note what was discussed, even if no concrete care decisions were made.
During the training, the GP will be instructed to upload this documentation to the patient’s electronic medical file.
With the patient’s permission, this information can be shared with other health providers involved in the patient’s care, such as specialist practitioners and home care nurses