Table 1 Description of the ACP intervention and summary of the results of the implementation study

The intervention [17]:

The goal was implementation of ACP in routine (everyday) GP care for older people. The intervention involves a two-step process in which the GP works together with the home care nurse, certified nursing assistant or with the practice nurse to implement ACP. The intervention was delivered by the professionals working in the 12 participating organisations. All the professionals involved were regular care providers of the patients, so no new people were introduced with the delivery of ACP. Health care professionals received amongst others, a training, a manual and conversation aids. The care providers decided which patients they would invite for an ACP discussion. Of course patients did not have to accept the invitation. In addition, conversations could also be initiated by patients themselves. Patients have a first conversation with a home care nurse, a certified nursing assistant or with the practice nurse. Subsequent conversations are with the GP. Our advice to staff was to have one ACP conversation per week to build up experience (we expected this to still be feasible in daily practice). The number of conversations per patient was not determined in advance.

Results of the implementation study [17]:

Results in the number of ACP conversations and advance directives were modest but positive; ACP conversations were offered to or started with 26% of older patients enlisted with participating organisations. ACP was implemented as routine care. Within respondents who filled in both the pre- and post-test questionnaire (AQ: correct?)(n = 458), more people had spoken to their GP about hospitalisations (OR 1.66 (1.18 – 2.32)), IC admission (OR 2.12 (1.40 – 3.22)), and treatment preferences in certain circumstances (OR 2.01 (1.42 – 2.84)) after implementation of ACP, compared to before. Advance Directives were drawn up more often (OR 1.54 (1.18—2.00)) after implementation, compared to before.