Skip to main navigation menu Skip to main content Skip to site footer

QI - Research Article (High Value Care Club)

Vol. 21 No. 1 (2023)

Advance Care Directives : A Herzl Clinic Quality Improvement Project

January 24, 2022


Background: Advance Care Planning has benefits for patients and is often optimal when done in the primary care setting. Unfortunately, it does not occur frequently or routinely. The goal of this project was to understand the challenges and barriers that residents at a Family Medicine training site face in initiating and discussing Advance Care Directives.


Methods: An online survey was conducted among 50 Family Medicine residents at the Herzl clinic. Participants were asked about their experience, their comfort level, and their challenges with Advance Care Planning discussions.


A focus group with 12 Family Medicine residents further probed, through open-ended questions, the specific challenges they have faced during Advance Care Planning and ideas to address them.


Results: The online survey and focus group identified that most residents perceived a lack of time, inadequate training, and poor uptake of available tools as barriers to have Advance Care Planning discussions in a community setting. Residents also felt that patients were inadequately prepared for these discussions. For improvement, most residents suggested to increase the variety of teaching modalities, to dedicate time for these discussions and to prioritize in-person discussions.


Conclusion: The residents in Family Medicine face many challenges and barriers to having Advance Care Directives discussions with their patients but were able to provide avenues for improvement.


  1. Directives médicales anticipées : Loi concernant les soins de fin de vie. Bibliothèque et Archives nationales du Québec, 2018 Bibliothèque et Archives Canada, 2018 ISBN 978-2-550-82963-8 (Imprimé) ISBN 978-2-550-82964-5 (PDF) (
  2. (
  3. Detering K, Silvester W, Corke C, Milnes S, Fullam R, Lewis V, Renton J. Teaching general practitioners and doctors-in-training to discuss advance care planning: evaluation of a brief multimodality education programme. BMJ Support Palliat Care. 2014 Sep;4(3):313-21. (doi: 10.1136/bmjspcare-2013-000450)
  4. Wickersham E, Gowin M et al. Improving the Adoption of Advance Directives in Primary Care Practices. The Journal of the American Board of Family Medicine. March 2019, 32 (2) 168-179. (doi: 10.3122/jabfm.2019.02.180236)
  5. Sedhom R, Sedhom D and Barlie D. Resident Discomfort in Advance Care Planning: Insights from a Multicenter Survey. Annals of Clinical Research and Trials. 2017; 1 (1). (
  6. Howard M, Bernard C, Klein D, et al. Barriers to and enablers of advance care planning with patients in primary care: Survey of health care providers. Can Fam Physician. 2018;64(4):e190-e198. (
  7. O’Sullivan R, Mailo K. et al. Advance directives. Canadian Family Physician. Apr 2015, 61 (4) 353-356. (
  8. Tung EE, North F. Advance care planning in the primary care setting: a comparison of attending staff and resident barriers. Am J Hosp Palliat Care. 2009 Dec-2010 Jan;26(6):456-63. (doi: 10.1177/1049909109341871)
  9. Coppola KM, Ditto PH et al. Accuracy of Primary Care and Hospital-Based Physicians' Predictions of Elderly Outpatients' Treatment Preferences With and Without Advance Directives. Arch Intern Med. 2001;161(3):431-440. (doi: 10.1001/archinte.161.3.431)
  10. Howard M, Langevin J, Bernard C, Tan A, Klein D, Slaven M, Barwich D, Elston D, Arora N, Heyland DK. Primary care clinicians' confidence, willingness participation and perceptions of roles in advance care planning discussions with patients: a multi-site survey. Fam Pract. 2020 Mar 25;37(2):219-226. (doi: 10.1093/fampra/cmz050)
  11. Spoelhof GD, Elliott B. Implementing Advance Directives in Office Practice. Am Fam Physician. 2012 Mar 1;85(5):461-466. (
  12. Myers J, Cosby R, Gzik D, Harle I, Harrold D, Incardona N, Walton T. Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review. Am J Hosp Palliat Care. 2018 Aug;35(8):1123-1132. (doi: 10.1177/1049909118760303.)
  13. Basu S, Swil K. Paediatric advance care planning: Physician experience and education in initiating difficult discussions. J Paediatr Child Health. 2018 May;54(5):510-514. (doi: 10.1111/jpc.13818.)
  14. Pottash M, Joseph L, Rhodes G. Practicing Serious Illness Conversations in Graduate Medical Education. Med Sci Educ. 2020;30(3):1187-1193. Published 2020 Jun 3. (doi:10.1007/s40670-020-00991-4)
  15. Frydman JL, Hauck K, Lowy J, Gelfman LP. Improving the Care of Patients With Serious Illness: What Are the Palliative Care Education Needs of Internal Medicine Residents? Am J Hosp Palliat Care. 2021 Oct;38(10):1218-1224. (doi: 10.1177/1049909120987207.)
  16. Crichton T, Schultz K, Lawrence K, Donoff M, Laughlin T, Brailovsky C, Bethune C, van der Goes T, Dhillon K, Pélissier-Simard L, Ross S, Hawrylyshyn S, Potter M. Assessment Objectives for Certification in Family Medicine. Mississauga, ON: College of FamilyPhysicians of Canada; 2020 (
  17. Nair D, El-Sourady M, Bonnet K, Schlundt DG, Fanning JB, Karlekar MB. Barriers and Facilitators to Discussing Goals of Care among Nephrology Trainees: A Qualitative Analysis and Novel Educational Intervention. J Palliat Med. 2020 Aug;23(8):1045-1051. (doi: 10.1089/jpm.2019.0570.)
  18. Levy D, Strand J, McMahon GT. Evaluating Residents' Readiness to Elicit Advance Care Plans. J Grad Med Educ. 2015 Sep;7(3):364-8. (doi: 10.4300/JGME-D-14-00542.1)
  19. Kononovas K, McGee A (2017) The benefits and barriers of ensuring patients have advance care planning. Nursing Times; 113: 1, 41-44. (
  20. Smith CS, Irby DM. The roles of experience and reflection in ambulatory care education. Acad Med. 1997 Jan;72(1):32-5. (
  21. Chan D, Ward E, Lapin B, Marschke M, Thomas M, Lund A, Chandar M, Glunz C, Anderson V, Ochoa P, Davidson J, Icayan L, Wang E, Bellam S, Obel J. Outpatient Advance Care Planning Internal Medicine Resident Curriculum: Valuing Our Patients' Wishes. J Palliat Med. 2016 Jul;19(7):734-45. ( doi: 10.1089/jpm.2015.0313.)


Download data is not yet available.