Table 2.

Clinician Perceptions of Group Visits for Advance Care Planning

ThemeParticipant IDQuotationSpecialty
1. Inherent properties of a group visit
Double-edged sword
104“I think the strength is that people can empathize with one another and once they hear other people maybe vocalizing the same concerns or opinions, they feel more comfortable in their own [situation] that they're not alone.”IM
106“So I think that the education that can be done in a group visit would be very helpful. But the discussion aspect of it, I think is going to depend on their [participant's] personality and really how sort of extroverted versus introverted they are: how comfortable they are.”FM
112“I could see some unintended consequences of just upsetting the other members [group participants] if things get too personal details in a group setting. I mean, I think you want people to open up, but it's a balance. There's a risk. Things could get too personal and too graphic.”IM
Risk–benefit ratio
102“I think even people that feel like they wouldn't benefit from it, I feel like it's something that they can benefit from.”IM
104“I think it's a great idea [group visits for advance care planning]. I think it's overdue and it'd really be nice if this can be accomplished outside of the physician visit, at least the groundwork…Sometimes it's just really hard, almost like pulling teeth, because people don't have a good understanding of or are repressed thinking about their lack of independence, or their dying days. And they're not forced to think about it because we, in American society, want to always think about having a happy ending and think happy thoughts.”IM
2. Purpose of group visits for advance care planning
102“I think one important thing is the setup; the way it's introduced and why it's being introduced and kind of painting a picture that this is something that is, should, be done with everybody, basically.”IM
109“When you make it [ACP] in a group setting, it sort of normalizes it and they [participants] can see examples of how its's used and why it's important and maybe [it] kind of reduces the stigma a little bit.”FM
119“People in the room [group visit participants] may have very different things going on with their health. I think just generally explaining the importance of advance care planning and the role that it plays in medical care is important, and I think as a way of kind of destigmatizing it that this is just a routine set of questions we ask everyone; I think that's fine. But beyond that I think making it work for everyone can be tricky.”Pall.
General education
104“So I think the group discussion would be like… an introduction and opens up, 'What are you facing down the road?' And, 'what are the options in terms of once you lose your independence for living?' And, 'what are the options in terms of when you're looking at the end of your days?'”IM
105“I think that a group visit would be helpful to disseminate general information more efficiently…I also see it being helpful, maybe having multiple people there for multiple questions and answers.”FM
108“Your goal [group visits] is just to expose them [participants to ACP], provide an avenue, and just hope they had a pleasant experience and maybe consider themselves more knowledgeable. But really not more, you know, like 'have decided one way or the other' necessarily.”FM
Prime the pump
107“A lot of patients are able to open up a little bit more, particularly when they are among their peers addressing their similar concerns and struggles. They're able to relate…There's actually some therapeutic counseling element, as well, in that. And so I think in the context of advanced directive, if you're giving general information and kind of like discussing how individuals feel about it, that definitely is a primer to when they would maybe even discuss it with their physician or when they go to complete paperwork and discuss it with their family.”FM
112“So maybe they [group visit participant] come to me with an advance directive form [from the group visit] and have had some time to read it, digest it, and then they come to me with specific questions about their situation. That could be helpful. I think having them be aware of some of these trade-offs: quality of life versus longevity—again, so that they're primed to speak about these issues, goals of care issues—could be helpful.”IM
Tools for action
113“That group discussion [visit] could be just like where the patient could be a springboard to introduce topics and let them research more topics. Gives you insight as to what they'd like to talk about and what issues they want addressed when they come to see you [clinician].”Cardiol.
101“I think explaining to them what advance care planning is, what forms are recommended to have, how logistically do they accomplish getting those forms to be legal documents, would be really great before [the clinician] talking to them about it because then you could just focus on more of the substance of it. About what they would want rather than how do I make this happen once I've made my decision.”FM
3. Format and procedures for group visits for advance care planning
103“I think we're targeting older adults [for advance care planning] for good reasons, but really, it should be part of basic primary care. And an important part of it, I think.”FM
104“Anybody who I felt did not lack capacity to make decisions for him- or herself either due to mild cognitive impairment or diagnosed with dementia, I would not refer…But other than that, I literally think that everybody could benefit from such a discussion.”IM
118[The most appropriate patients for ACP group visits] “I guess it would be the stable patients that we have already exhausted all of our treatment options and we're kind of managing them and just providing surveillance.”Cardiol.
Organizing groups by a characteristic
113“So you want to pick and choose your patients. Obviously you want to introduce the topic to everybody, but you want to really refer the people who are the most enthusiastic and could really augment a session and really ask in-depth questions and really move the discussion along.”Cardiol.
114“The patients who don't have a high risk of mortality in the next few years I don't think are appropriate for that kind of group therapy or group session.”Cardiol.
116“Well, it would be nice having people in similar circumstances brought together.”IM
Link back to clinician
111“I think just being sure that the paperwork's done and in the chart is basically all that really needs to happen.”FM
112“I think a general list of topics that were covered and then specifically after it [group visit] happens, a brief—and by “brief” I mean four or five bullet points—sort of the outcomes of the group visit. Did the group get sidetracked and not cover what a POLST form is? Did they not get past the quality of life versus longevity discussion? Did the conversation deteriorate? So four or five bullet points summarizing the extent to which topics were actually covered [documented] through the electronic health record.”IM
115“I always believe that if you are able to educate patients about their disease process, give them the support that they need, provide them with resources, and connect the provider along with the patient and the family that they do the best.”Cardiol.
119“I would want to know what's going to be discussed in the visit and by who[m].”Pall.
  • ACP, Advance care planning; POLST, physician orders for life-sustaining treatment; Internal Medicine; FM, Family Medicine; Cardiol, Cardiology.