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Table 5 CLaD intervention content description mapped to intervention type and behaviour change techniques (BCTs)

From: Development of a theory-based intervention to increase cognitively able frail elders’ engagement with advance care planning using the behaviour change wheel

CLaD content description Intervention type Core BCTs
• Understand frailty and the relevance of ACP
• Revise/recap fluctuating physical and mental capacity and sudden deterioration.
• Discuss impact of not having an ACP for frail elders and family.
• Explain the importance of early engagement, and the impact of leaving ACP too late e.g. missing the greatest opportunity to engage physically and cognitively.
• Revise/recap triggers for ACP discussions (e.g. hospitalisation, deterioration, infection, family issues).
Education 5.1, 5.6
Shown film section discussing uncertainty.
• Discuss as a group how to communicate uncertainty, fluctuating capacity and sudden deterioration with frail elders and families
• Discuss and practice communicating key triggers with frail elders and families
Training 4.1, 6.1, 8.1
Understanding why ACP is different for frail elders
Show film section discussing challenges of ACP to frail elders. Discuss:
• lack of clarity and confusion around ACP for frail elders
• relevance of ACP for frail elders
• shared rather than autonomous decision-making
• importance of family and living well now engaging frail elders with ACP
• protecting family and family difficulties in engaging.
Education 4.2, 5.1, 5.6
Living well now
Show film section on living well now.
• Revise challenges around relevance of ACP to frail elders.
• Explain importance of living well now, in the moment, for frail elders.
• Explain importance of establishing what is important to the frail elders in terms of living well now and thinking about planning for the present and short-term future.
• Explain and demonstrate strategies for engagement e.g. focussing on the frail elder’s values, including those they would rather avoid.
• Explain/demonstrate strategies to explain the relevance of ACP to frail elders.
• Discuss and practice how to help explain the relevance of ACP to frail elders focussing on their values and beliefs, and how to talk about parallel planning.
Education and Training 4.2, 5.1, 6.1, 8.1
Make ACP more relevant for frail elders
• Explain strategies to help engage frail elders with ACP including making ACP more relevant by using frail elder’s health care experiences, or those of family/friends, vignettes, storytelling, or reminiscence
Education 4.2, 5.1
Prepare frail elders for ACP conversations
Show film section re being prepared.
• Explain why frail elders need to have time to prepare for ACP.
• Explain the importance of family in preparing for ACP conversations.
• Explain the importance of enabling a conducive environment (usually in own home, with their family/friends around them)
• Explain and demonstrate strategies for preparing frail elders for ACP, focussing on goals and preferences, and including family e.g. “Next time would like to talk about…” “You might like to think about” “Why not discuss with….”.
• Explain the importance/recommend providing frail elder a Hospice/other ACP leaflet and asking them to look at this/discuss with their family prior to the ACP conversation.
• Discuss and practice how to help frail elders to prepare for ACP conversations.
Education, Enablement & Training 1.4, 4.1, 4.2, 5.1, 6.1, 8.1, 12.5
Remember relationships
Show film section re family.
• Explain why family are important to ACP decisions for frail elders.
• Encourage frail elders to speak to family about ACP/ACP decisions.
• Explain and demonstrate strategies for including family in ACP discussions.
Discuss and practice:
• how to encourage family inclusion;
• how to facilitate conversations between the frail elders and their family
• how to help family understand the frail elder’s wishes.
Education 4.1, 4.2, 5.1, 6.1, 8.1
Use the right approach to ACP conversations
Show film section re approach. Explain:
• why conducting ACP as normal, every-day conversations is important.
• why using every opportunity to engage frail elders with ACP is important.
• why ACP as a process is important.
• what is meant by gentle language and a light-hearted approach.
• the importance of pacing and likely outcomes of taking ACP too fast or slow.
Shown film section re being honest and frank.
• Explain that frail elders state they prefer an honest, frank approach e.g. whether any current or future care choices are likely or possible e.g. ceilings of treatment, dying in a hospice.
• Discuss and practice approaches to ACP for frail elders.
• Refer to toolkit which includes relevant language.
Education & Training 4.1, 4.2, 5.1, 6.1, 7.1, 8.1
Communicate and confirm understanding of ACP
Show film section regarding ACP confusion for frail elders and families. Explain:
• the importance of using clear, understandable language and minimising jargon/euphemisms, e.g. using “your values and preferences for your care” or “care wishes” or other clear terminology rather than “ACP”.
• the importance of summarising and confirming understanding with frail elders
• the importance of managing expectations e.g. recovery potential, medical outcomes, what services may be available and correcting any misunderstandings.
Education & Training 4.2, 5.1, 4.1, 6.1, 7.1
Overarching support and revision
Revise and recap:
• importance of ACP, family and relationships in decision-making, and living well now.
• why starting ACP early is important e.g. to allow for potential deterioration and response shift.
• that ACP for frail elders is more about shared than autonomous decision-making.
• the suggested approach to ACP with frail elders.
• why ACP for frail elders needs to be introduced prior to the ACP conversation
• why ACP needs revising regularly
• why family can be important in preparation for ACP conversations.
• H&SCPs given toolkit to prompt recollection of strategies, language, triggers and the importance of preparation, reassessment and family inclusion.
• Discuss previous positive experiences of good ACP conversations with frail elders as a group.
• Recommend the approach is thought of as a process, and a strategy to enable frail elders to live their best life, rather than a tick box, one-off exercise.
• Advise staff that their approach to ACP for frail elders will be an example to others
• Recommend H&SCPs contact the PI or an intervention colleague if they wish to discuss any challenges.
• Suggest H&SCPs support each other to develop their ACP skills with frail elders.
Environmental restructuring, Persuasion and Training
Modelling and Enablement
4.1, 5.1, 6.1, 7.1, 8.3, 9.1, 12.5,13.1, 13.2, 15.3
3.1, 3.2
  1. Intervention types (from BCW [37]): Education = Increase knowledge/understanding; Enablement = Increase means/reduce barriers to capability/opportunity; Environmental restructuring = Change physical/social setting; Modelling = Provide examples to imitate/aspire to; Persuasion = Provoke positive/negative feelings, motivate action; Training = Develop skills. BCT codes (from BCT taxonomy version 1 [58]): 1.4 = Action planning; 3.1 = Social support (unspecified); 3.2 = Social support (practical); 4.1 = Instruction on how to perform the behaviour; 4.2 = Information about antecedents; 5.1 = Information about health consequences; 5.6 = Information about emotional consequences; 6.1 = Demonstration of the behaviour; 7.1 = Prompts/cues; 8.1 = Behavioural practice/ Rehearsal; 8.3 = Habit formation; 9.1 = Credible source; 12.5 = Adding objects to the Environment; 13.1 = Identification of self as role model; 13.2 = Framing/reframing; 15.3 = Focus on past success