Table 3 Inclusion and exclusion criteria for participants in this study

Group 1: People with Chronic Diseases

▪ Patients aged ≥18 years old

▪ Admitted to the wards/community centres in participating hospitals and community settings,

▪ Identified in Medical Records as having a chronic health condition(s) (defined within this research project as; Diabetes, Congestive Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Cancer, Frailty and Dementia.

▪ Patients who do not currently have an Advance Care Directive

▪ Women who are pregnant and the human foetus.

▪ Children and/or young people (< 18 years old).

▪ People highly dependent on medical care.

▪ People who are experiencing acute severe physical illness and/or an acute episode of mental illness (a diagnosis of anxiety alone may not exclude participation)

Group 2: Substitute Decision Makers (SDMs)

• ≥18 years old

• Nominated as an SDM by people with chronic diseases at intervention site

• The ability to give valid informed consent

▪ Children and/or young people (<  18 years old).

▪ People who are experiencing acute severe physical illness and/or an acute episode of mental illness (a diagnosis of anxiety alone may not exclude participation)

Group 3: Admitting Healthcare Professionals (MOs, RNs, &/or SW) at intervention sites (normalisation agents level one, or NA1)

▪ ≥18 years old

▪ The ability to give valid informed consent

▪ Working in a professional capacity admitting patients to one of the research units listed, or

▪ Employed and trained as a NA2 for this research study.

▪ Not working in one of the research units listed

Group 4: RNs delivering the intervention (referred to as ‘RN ACP Facilitators’) at intervention sites (normalisation agents level two, or NA2).

▪ ≥18 years old

▪ The ability to give valid informed consent

▪ Employed and trained as a NA2 for this research study.

▪ Not employed and trained as a NA2 for this research study