Confrontational but important – A mixed-methods evaluation of the MUTUAL (Multidisciplinary timely undertaken advance care planning) intervention

Introduction: The Multidisciplinary Timely Undertaken Advance Care Planning (MUTUAL) intervention was developed to facilitate early initiated and structured advance care planning (ACP) at outpatient clinics. This study explores stakeholder evaluations of MUTUAL after its implementation. Methods: A sequential explanatory mixed-methods study was conducted at seven outpatient clinics at one non-academic Dutch hospital. Patients, nurses, and physicians completed questionnaires after participating in an ACP conversation. Quantitative analysis of the questionnaire results was supplemented by a qualitative analysis of open comments, and semi-structured interviews were conducted with patients and proxies. Results: For 216 ACP conversations, responses were received from 121 patients (response rate 57.9 %) and from 136 nurses and 116 physicians (response rates 65.1 % and 55.5 %). Overall, 80.1 % of conversations were evaluated by at least one stakeholder. All stakeholders rated the ACP conversations as worthwhile (4.6–4.8 out of 5) and expressed satisfaction (scores of 8.6, 7.8, and 8.3 out of 10 for patients, nurses, and physicians, respectively). Three themes were identified. First, we found a diversity of patient paths within the ACP process. MUTUAL facilitated reflection and open dialog at various stages, leading to valuable discussions despite sometimes confrontational end-of-life topics. Second, stakeholders had varying perspectives on what makes the ACP conversation valuable. Some HCPs emphasize the importance of making treatment decisions. Others value the opportunity to address patient concerns even without changes to the treatment decisions of the patient. Third, having time and a structured setting outside regular outpatient consultations fostered trust and openness; HCPs’ empathy and expertise were appreciated, seemingly regardless of prior established relationships. Conclusion: MUTUAL was positively received by stakeholders, even when evoking mixed emotions. By encouraging broader discussions beyond immediate treatment decisions, the intervention promoted reflection, reassurance, and ongoing conversations. Findings support an adaptable, multi-stakeholder ACP approach in which HCPs act as guiding partners for patients during their (chronic) illness journeys.