Table 3 Illustrating quotes from interviews

#1

7a

“I believe the conversations are very valuable since they help you to get to know the patient and what matters to him/her. Patients really appreciate it [having the ACP conversations]. Personally, I also like this and the fact that they say they appreciated talking about this [what is important to them] […].” (int 1., nurse)

#2

7a

“The additional value of the ACP intervention is that it creates a starting point for discussion for later conversations. […] and it can be useful to refer to in later conversations: remember, we have talked about this and this is what you mentioned […]. The multidisciplinary setting helps [getting the wishes of the patient known] since the nurse is able to retrieve other information using the preparatory questionnaire than I am able to retrieve during a normal outpatient encounter with the patient […].” (int.4, physician)

#3

7a

“Some people are not realistic, and their wishes contain many contradictions. [For example] If a patient states that it is essential to have a certain quality of life, and at the same time still wishes to be admitted to an intensive care unit [if necessary]. If you think [as a healthcare professional] that these wishes are conflicting, then it is your duty to inform the patient about what admission to an intensive care unit looks like, what the potential consequences are, and what the chances of recovery are.” (int 2., nurse)

#4

8a

“Sometimes when we are asked to think [in our consultative function] along with patients on the ward, for example whether a patient has a delirium, [if] it turns out that the patient does not want to be treated anymore […] then we advise an ACP conversation or ask the palliative care team for advice.” (int.9, nurse)

#5

8f

“It is fulfilling to have these kinds of [ACP] conversations, because you are able to help a patient in the process [of ACP], in becoming more aware […], because [you are also able to help] if questions arise concerning end of life matters.” (int.7, nurse)

#6

8 g

“It is something you have to grow into, to have these kinds of conversations, to ask the right open questions, to notice the right things. A lot of it is subjective, it’s about what you see and what you feel. That’s something you must get acquainted with.” (int.2, nurse)

#7

9a

9b

9c

“Even if patients did not fill in the preparatory questionnaire, they have read the questions and thought about it. […] It [the preparatory questionnaire] helps the patient to understand the goal of the conversation.” (int.1, nurse)

#8

23a

“I only see patients once or twice a year [at the outpatient clinic]. Those people have a lot of questions and there are so many things they want to know. To say, in addition, in that situation, let’s talk about ACP … you just don’t get around doing that. There is simply no time for it.” (int. 11, physician).

#9

20a

23b

“There was a time when one nurse had just retired and the other one was almost completely on her own. That might have unconsciously made you feel like “okay, we’re not going to have a formal ACP conversation, I will just do it [discuss treatment preferences] myself.” (int. 5, physician)

#10

6

“The [ACP] letter ‘disappears’ in the medical healthcare system, it just falls away. I am not sure if everyone [the involved healthcare professionals] is informed of the existence of the ACP letter. If, for example, a patient is admitted for surgery nine months after the ACP conversation, then I am not sure if the letter will be noticed and read.” (int.7, nurse)

#11

6

“But at some point, the patient goes back to the general practitioner. We never receive information afterwards. I have only had that [received information] once, that was precious. [I heard that] the ACP letter had been helpful and that the patient didn’t get resuscitated and he died the way he wanted to. I only got that feedback once. I think it would be nice for me and my colleagues to know that what we are doing [having ACP conversations] is helpful in the domestic atmosphere. It helped me to hear that from the general practitioner.” (int.1, nurse).

#12

23b

“What is important [for organising the ACP conversations], is the support from nurses, they have to be able to spend a certain amount of time per week having these conversations […]. The organisation should create the conditions, [to enable implementation of the ACP intervention]: the time, and support from nurses.” (int. 10, physician).