Barriers and facilitators of navigator-led advance care planning conversations in older patients with cancer.

17 Background: National guidelines and most individuals endorse advance care planning (ACP) as essential; however, few individuals engage in such planning. Little is known about the role of lay navigators in supporting ACP. We sought to understand facilitators and barriers of successful implementation of ACP conducted by lay cancer navigators.

METHODS: Semi-structured interviews were conducted with 26 lay navigators at 11 sites across the Southeast who were engaged in ACP implementation using Respecting Choices©. Interview topics included quality of ACP training, ACP conversation knowledge and comfort, barriers and facilitators, and perceived role in navigating patients with advanced cancer. Audio-recorded interviews were transcribed verbatim; thematic content analysis was conducted using NVivo 10 Software. Transcripts were reviewed for major themes and subthemes generated via line-by-line coding. Inter-rater agreement (2 primary coders) was assessed using Cohen's Kappa ( = 0.81), indicating high agreement.

RESULTS: Navigators completed 672 ACP conversations across sites. Facilitators and barriers emerged across 3 domains: patient, navigator, and system domains. System facilitators included physician engagement and oncology-team consultation support while barriers included lack of time and space, lack of stakeholder support, and cultural suspicion. At the navigator level, established rapport was a necessary facilitator while personal discomfort and timing issues were barriers. At the patient level, prior experience with a family member was a facilitator while barriers included limited health literacy, fears, lack of readiness, and a "battle" mentality.

CONCLUSIONS: Lay navigators can be trained to facilitate advance care planning conversations with cancer patients. Lay navigators identified several areas where additional training and infrastructure support might facilitate ACP in patients with advanced cancer. Future work should focus on designing and evaluating systems of healthcare delivery to support this activity.