Contrasting Approaches in Advance Care Planning in Dementia as Perceived by General Practitioners

BackgroundVarious approaches to advance care planning are being used, also for persons with dementia and their care partners. Two contrasting approaches involve a highly scripted, predominantly medical approach to decide on specific treatments in advance versus a more flexible psychosocial, coping-based approach comprising global care goal setting. ObjectiveTo assess situations in which either approach is preferred in dementia from the perspective of general practitioners. MethodsWe interviewed thirteen practitioners participating in the Dutch CONT-END study; seven were trained in the medical approach and six were trained in the psychosocial approach. We explained the other approach during the interview. Twelve other practitioners were interviewed after viewing video vignettes of the two approaches shown in random order. Inductive qualitative content analyses was guided by the aim to elucidate for whom and when an approach was preferred. ResultsFour attributes distinguished situations in which either approach is preferred: understanding, trust, readiness and momentum. For the medical approach, understanding, trust, and readiness on part of person and care partner were prerequisites for optimal momentum, which, however could also be triggered by urgent medical reasons. In contrast, the psychosocial approach would help understand the person, foster trust and create readiness from a first conversation. Without a clear trigger, however, momentum would need to be created. ConclusionsSkill in employing various approaches to ACP conversations each with specific benefits could help tailor ACP to the individual and their situation. Further theoretical and empirical research including in other populations and settings may inform person-centred ACP. Key PointsA medical versus a more psychosocial approach to advance care planning (ACP) in dementia can be typified by contrasts within four attributes: understanding, trust, readiness and momentum. Although both approaches are appropriate in itself, either is superior depending on the situation of the persons involved, and the psychosocial approach may be particularly suitable for a first conversation initiated by a professional caregiver. Further theoretical clarification and empirical research could enhance and refine ACP training programs and inform person-centred ACP in more diverse practices and populations.