Bridging the advance care planning training gap

Introduction

Advance care planning (ACP) is a patient-centred process facilitating discussion and documentation of future care preferences. Although medical graduates are expected to be competent in ACP, many report low confidence in conducting these conversations. Simulation-based teaching addresses this gap, but approaches are heterogeneous and rarely incorporate structured ACP documentation tools. We evaluated the feasibility and impact of a proforma-integrated ACP simulation programme on trainee knowledge, communication skills, and empathy. 

Method

We conducted a single-centre mixed-methods pilot study at Broomfield Hospital involving 20 Year 3–5 medical students and Foundation Year 1 doctors. Participants attended a 15-minute didactic seminar followed by three Proactive Elderly Advance CarE (PEACE) plan-based simulation scenarios (two peer-to-peer and one facilitator-led) with structured debriefing. Pre- and post-intervention surveys evaluated outcomes across Kirkpatrick Levels 1–3, confidence across 11 ACP skill domains, and empathy using the Jefferson Scale of Empathy (JSE). Quantitative data were analysed using Wilcoxon signed-rank tests, while free-text responses underwent knowledge-domain coding and thematic analysis. 

Results

At baseline, participants demonstrated limited understanding of ACP, with barriers including managing emotional distress, structuring conversations, and limited prior knowledge. Following the intervention, participants reported greater ACP understanding, familiarity with legal frameworks (median 3.0 vs 7.0; p<0.001), and confidence across all 11 skill-based domains (p<0.001). Knowledge-domain coding demonstrated broader understanding, including greater recognition of standardised ACP proformas, legal frameworks, prognosis, and capacity assessment. Qualitative analysis suggested a shift from general uncertainty towards greater awareness of prognostic uncertainty and family conflict. JSE scores showed a modest but significant improvement post- intervention (median 106 vs 107; p=0.020).  

Conclusion 

PEACE plan-based simulation was associated with significant improvements in ACP knowledge, confidence, and attitudes, supporting its feasibility as an intervention. Further controlled studies with longitudinal follow-up are needed to determine whether these improvements are sustained and translate into clinical practice.