Table 4 Barriers and suggestions for improvement based on interviews and comments/answers to open-ended questions contained within the MIDI

1. Intervention is perceived as demanding

User – 8i

1) Create a memory card with supporting questions for the different theme’s discussed within the ACP conversation.

2) Have manageable expectations within the ACP conversation: “You can’t always reach your goal, but that doesn’t mean you did not have a good conversation. Most important is that the patient gets insight into what matters most and you start the process of ACP.”

3) The development of skills is important and demands the ability for self-reflection. It helps to include other healthcare professionals in this process.

2. Intervention raises workload

User – 8j

1) Optimise administrative support (e.g., for planning ACP conversations, and support for documentation).

2) Create a backup system for having ACP conversations (e.g., nurses from the palliative care team could have ACP conversations at other outpatient clinics in case of a lack of capacity).

3. Less than half to not a single colleague from my specialty use/uses the ACP intervention

User – 14

1) Frequent (e.g., monthly) reminders to improve awareness for healthcare professionals.

2) Raise awareness within patients and their proxies.

3) Embed, structurally, ACP conversations within usual care, and create a routine.

4. No replacement of staff in a timely manner

Organisation – 20a

1) Prioritise replacing healthcare professionals who are able to have ACP conversations and support the timely preparation of healthcare professionals to enable them to have ACP conversations.

5. Insufficient capacity

Organisation - 21

2) Offering patients ACP conversations should be positioned as a standard medical procedure.

6. Insufficient time for introducing and inviting patients for an ACP conversation

Organisation – 23a

1) Explicate additional value and importance of having ACP conversations.

2) Prioritise the introduction of ACP conversations to patients during regular outpatient clinic visits.

3) Expand the means by which patients can be invited for an ACP conversation. This can include having the opportunity for other healthcare professionals (e.g., nurses or paramedical staff on wards or at outpatient clinics) to be involved, structurally, in the selection process. Also incorporate, structurally, discussions surrounding the selection of patients at other meetings, including multidisciplinary ones.

7. Influence of Covid-19

Organisation – 26a

1) No specific suggestions for improvement.

8. Other projects

Organisation – 26b

1) No specific suggestions for improvement.

Other tips/suggestions

Not applicable

1) Encourage general practitioners to have ACP conversations and share advance directives with treating physicians and incorporate these [advance directives] structurally into referral letters.

2) More support from management.

3) More awareness for palliative care in general.