title: A clinical framework for improving the advance care planning process: start with patients' self-identified barriers.
abstract: OBJECTIVE
  To explore barriers to multiple advance care planning (ACP) steps and identify common barrier themes that impede older adults from engaging in the process as a whole.
  
  
  METHODS
  Descriptive study.
  
  
  METHODS
  General medicine clinic. San Francisco County.
  
  
  METHODS
  One hundred forty-three English and Spanish speakers aged 50 and older (mean 61) enrolled in an advance directive preference study.
  
  
  METHODS
  Six months after reviewing two advance directives, self-reported ACP engagement and barriers to each ACP step were measured with open- and closedended questions using quantitative and qualitative (thematic content) analyses.
  
  
  RESULTS
  Forty percent of participants did not contemplate ACP, 46% did not discuss with family or friends, 80% did not discuss with their doctor, and 90% did not document ACP wishes. Six barrier themes emerged: perceiving ACP as irrelevant (84%), personal barriers (53%), relationship concerns (46%), information needs (36%), health encounter time constraints (29%), and problems with advance directives (29%). Some barriers were endorsed at all steps (e.g., perceiving ACP as irrelevant). Others were endorsed at individual steps (e.g., relationship concerns for family or friend discussions, time constraints for doctor discussion, and problems with advance directives for documentation).
  
  
  CONCLUSIONS
  Perceiving ACP to be irrelevant was the barrier theme most often endorsed at every ACP step. Other barriers were endorsed at specific steps. Understanding ACP barriers may help clinicians prioritize and address them and may also provide a framework for tailoring interventions to improve ACP engagement.
authors.affiliation: University of California at San Francisco, 94121, USA.
authors.forename: Adam D
authors.initials: AD
authors.lastname: Schickedanz
authors.forename: Dean
authors.initials: D
authors.lastname: Schillinger
authors.forename: C Seth
authors.initials: CS
authors.lastname: Landefeld
authors.forename: Sara J
authors.initials: SJ
authors.lastname: Knight
authors.forename: Brie A
authors.initials: BA
authors.lastname: Williams
authors.forename: Rebecca L
authors.initials: RL
authors.lastname: Sudore
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011795:Surveys and Questionnaires