Implementing Advance Care Planning in Acute Hospitals: Leading the Transformation of Norms.

Background: Despite being simply defined as a process to further one's understanding about future medical care, the process of implementing advance care planning (ACP) within acute hospital settings can be complex.

Aim: We describe different ACP service models adopted in Singapore, and the facilitators for, and barriers to, its effective implementation.

Design: Qualitative focus group study with thematic analysis.

Settings/participants: We purposefully sampled four stakeholder groups involved in the implementation of ACP. Our sample included 63 participants, 12 physicians, 15 nurses, 24 medical social workers, and 12 ACP coordinators from seven public hospitals and one specialist center.

Results: We describe three different acute-care models adopted in Singapore, differentiated by leadership approach, target population, delivery process, and job roles. Our results revealed nine themes, organized into four categories, including: (1) hospital culture (curative norms, absence of preference-supportive culture), (2) organizational priority and leadership (low priority on hospital agenda, inappropriate leadership), (3) goals and distinction (lack of shared purpose and goals, no clear differentiation from existing practices), and (4) work practices (pigeonholing of ACP practice, inappropriate resourcing, accountability and feedback).

Conclusion: We learned that to implement ACP effectively in an acute-care setting, there needs to be a cultural and behavioral transformation, led by committed and empowered leaders. Organizations that can create a shared purpose built on an ethos of honoring patients' preferences, and support this with systematic processes and adequate resourcing, will be more equipped to implement ACP effectively.