Vol. 67 No.

2 February 2024 Journal of Pain and Symptom Management 173

Review Article

The Impact of Advance Care Planning on Healthcare

Professionals’ Well-being: A Systematic Review
Lucas Gomes Souza, MD, MSc, Dalil Asmaou Bouba, MD, ENT, Roberta de Carvalho Cor^ oa, BSc, MSc, PhD,
Suel
ene Georgina Dofara, MSc, Vincent Robitaille, BSc(c), Virginie Blanchette, DPM, MSc, PhD, Kathy Kastner,
Frederic Bergeron, MSI, Sabrina Guay-B
elanger, MSc, PhD, Shigeko (Seiko) Izumi, PhD, RN, FPCN,
Annette M. Totten, PhD, Patrick Archambault, MD, MSc, FRCPC, and
France L egar
e, CQ, BSc Arch, MD, MSc, PhD, CCFP, FCFP
Department of Social and Preventive Medicine (L.G.S., D.A.B.), Faculty of Medicine, Universite Laval, Que bec, Canada, and VITAM, Centre
de recherche en sante durable, Centre inte gre universitaire de sante et de services sociaux de la Capitale-Nationale, Que bec, QC, Canada;
Department of Family Medicine and Emergency Medicine (R.C.C.), VITAM, Centre de recherche en sante durable, Unite de soutien au syste me
de sante apprenant, Centre inte gre universitaire de sante et de services sociaux de la Capitale-Nationale, Faculty of Medicine, Universite Laval,
Que bec, QC, Canada; VITAM, Centre de recherche en sante durable (S.G.B., S.G.D.), Centre inte gre universitaire de sante et de services
sociaux de la Capitale-Nationale, Que bec, QC, Canada; Faculty of Medicine, Universite Laval (V.R.), VITAM, Centre de recherche en sante
durable, Centre inte gre universitaire de sante et de services sociaux de la Capitale-Nationale, Quebec, QC, Canada; Department of Human
Kinetics and Podiatric Medicine (V.B.), Universite du Que bec a Trois-Rivie res, Trois-Rivie res, QC, Canada; Best Endings, Toronto, ON,
Canada; Bibliothe que de l’Universite Laval (F.B.), Que bec, QC, Canada; School of Nursing (S.I.), Oregon Health & Science University,
Portland, OR; Department of Medical Informatics and Clinical Epidemiology (A.M.T.), School of Medicine, Oregon Health & Science
University, Portland, OR; Department of Family Medicine and Emergency Medicine (P.A.), Faculty of Medicine, Universite Laval, VITAM,
Centre de recherche en sante durable, Centre inte gre universitaire de sante et de services sociaux de la Capitale-Nationale, Centre de recherche
inte gre e pour un syste me apprenant en sante et services sociaux, Centre inte gre de sante et services sociaux de Chaudie re-Appalaches, Que bec,
QC, Canada; Department of Family Medicine and Emergency Medicine (F.L.), Faculty of Medicine, Universite Laval, VITAM, Centre de
recherche en sante durable, Researcher, Centre de recherche du CHU de Que bec, Centre inte gre universitaire de sante et de services sociaux de la
Capitale-Nationale, Que bec, QC, Canada

Abstract
Context. Advance care planning (ACP) improves care for patients with chronic illnesses and reduces family stress. However,
the impact of ACP interventions on healthcare professionals’ well-being remains unknown.
Objective. To systematically review the literature evaluating the impact of ACP interventions on healthcare professionals’
well-being.
Methods. We followed the Joanna Briggs Institute methodology for systematic reviews and registered the protocol in PROS-
PERO (CRD42022346354). We included primary studies in all languages that assessed the well-being of healthcare professionals
in ACP interventions. We excluded any studies on ACP in psychiatric care and in palliative care that did not address goals of
care. Searches were conducted on April 4, 2022, and March 6, 2023 in Embase, CINAHL, Web of Science, and PubMed. We
used the Mixed Methods Appraisal Tool for quality analysis. We present results as a narrative synthesis because of their
heterogeneity.
Results. We included 21 articles published in English between 1997 and 2021 with 17 published after 2019. All were con-
ducted in high-income countries, and they involved a total of 1278 participants. Three reported an interprofessional interven-
tion and two included patient partners. Studies had significant methodological flaws but most reported that ACP had a possible
positive impact on healthcare professionals’ well-being.
Conclusion. This review is the first to explore the impact of ACP interventions on healthcare professionals’ well-being. ACP
interventions appear to have a positive impact, but high-quality studies are scarce. Further research is needed, particularly using

Address correspondence to: France Legare, CQ, BSc Arch, MD,
MSc, PhD, CCFP, FCFP, Department of Family Medicine and
Emergency Medicine, Laval University, 2480, Chemin de la
Ó 2023 The Authors. Published by Elsevier Inc. on behalf of
American Academy of Hospice and Palliative Medicine. This is an
open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Canardi ere, bureau 221, Quebec (QC) Qu ebec, QC G1G
2G1 Canada. E-mail: France.Legare@fmed.ulaval.ca
Accepted for publication: 16 September 2023.
0885-3924/$ - see front matter
https://doi.org/10.1016/j.jpainsymman.2023.09.026
174
more rigorous and systematic methods to implement interventions and report results. J Pain Symptom Manage 2024;67:173
−187. © 2023 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Key Words
Advance care planning, end-of-life discussions, goals of care, healthcare professionals, well-being, systematic review
Key Message
This systematic review suggests ACP may enhance
healthcare professionals’ well-being. However, a lack of
high-quality studies hinders conclusive findings. Fur-
ther research is needed to better explore the impact of
ACP on healthcare professionals’ well-being. Future
ACP interventions should aim to explore the well-being
of healthcare professionals aiming to improve health-
care quality and patient-centered care.
Rationale
Advance care planning (ACP) is a process that sup-
ports patients in sharing and clarifying their personal
values, life goals, and preferences regarding future
medical care. By engaging in ACP, patients participate
actively in their care and ensure their wishes are
expressed.1 ACP can also help healthcare professionals
better understand a patient’s goals and values, which
can then guide decision-making and improve the qual-
ity of care provided.1,2
In a review of 56 studies, Houben et al. assessed the
effectiveness of ACP and demonstrated that it improves
concordance between preferences and quality of com-
munication among professionals, patients, and their
loved ones.3 A review by Martin et al. showed that ACP
also reduces hospitalizations since it allows patients to
decide whether they want to be hospitalized in the
event of worsening underlying diseases.4 This suggests
that a wider use of ACP may reduce healthcare costs.
Together, these studies indicate that ACP interventions
achieve the “triple aim” of health system performance
as proposed by Berwick, Nolan, and Whittington,5 by
improving the health of populations, enhancing the
patient experience of care, and reducing the per capita
cost of health care.3−5
However, the triple aim may not be enough to
achieve ideal health system performance. The well-
being of professionals may have an equally important
impact on the performance of a health system.5,6
Therefore, a fourth aim focusing on the well-being of
healthcare professionals’ has been added to the frame-
work.6 Interventions that also address the fourth aim
have shown to be more effective and to help the health
system perform better, ultimately resulting in improved
patient outcomes.7−9 Despite its importance, research
Gomes Souza et al. Vol. 67 No. 2 February 2024
on the well-being of healthcare professionals is still rela-
tively recent in the literature. A systematic review
highlighted numerous factors influencing the well-
being of healthcare professionals, but a comprehensive
and precise definition remains elusive.10 Authors of
this review, in alignment with others in the field, associ-
ated well-being with high quality of life, encompassing
physical, mental, social, and integrated well-being and
an absence of ill-being. Well-being is experienced in
conjunction with activities and environments that allow
healthcare professionals to reach their full potential in
both their personal and work lives, positively impacting
both themselves and the organizations they serve.10−12
Dimensions of the well-being of healthcare profes-
sionals include burnout, job satisfaction, work engage-
ment, job distress, job-related depression, job-related
anxiety, quality of life, absenteeism, distress, emotional
health, as well as professional fulfillment, and satisfac-
tion.13 Various surveys have been developed to assess
each of these elements, but there is no single measure
for overall well-being. To incorporate the diversity of
dimensions that constitute the well-being of healthcare
professionals, this review adopts a broad definition of
well-being.10,13
Earlier primary studies and reviews have explored
the effects of other clinical interventions on healthcare
professionals well-being, such as diabetes manage-
ment,14 revealing a correlation between improved
patient satisfaction and enhanced healthcare professio-
nals well-being.15 However, the impact of ACP on the
well-being of healthcare professionals has not yet been
investigated.
While our systematic review acknowledges the sig-
nificance of a newly incorporated fifth aim, namely
equity,16 in improving healthcare system perfor-
mance, this study focused on the well-being of
healthcare professionals because there is a current
interest in this issue, and especially in how to
improve it. This topic is even more relevant and
important now since the Covid-19 pandemic
highlighted how much health systems depend on
the physical and mental resiliency of healthcare
professionals.17,18
While individual studies have addressed the impact
of ACP interventions on the well-being of healthcare
professionals,19−39 to the best of our knowledge no sys-
tematic review has synthesized the evidence on this
Vol. 67 No. 2 February 2024 ACP Interventions on HCP’s Well-being
topic. Moreover, there is reason to believe that ACP
interventions could substantially enhance the well-
being of healthcare professionals. First, ACP could alle-
viate moral distress among healthcare professionals.
Witnessing patients and their families struggle with
end-of-life decisions presents healthcare professionals
with painful moral dilemmas and can lead to emotional
exhaustion and burnout.40 By engaging in ACP discus-
sions with patients41 they may experience a sense of
relief and fulfillment in knowing they are actively sup-
porting their patients in their most difficult hour and
providing care that aligns with their preferences and
best interests.
Training healthcare professionals in ACP can also
positively impact healthcare professionals’ well-being
by giving them the skills and confidence necessary for
handling complex care situations, such as competence
in navigating difficult conversations about end-of-life
care, managing patient emotions, and addressing
potential conflicts.42 This enhanced competency fos-
ters increased confidence among healthcare professio-
nals in dealing with sensitive topics, reducing anxiety
and emotional distress in challenging patient care sce-
narios. As healthcare professionals become better
equipped to engage in open and honest ACP discus-
sions, they may experience improved job satisfaction
and a sense of empowerment in providing patient-cen-
tered care. Additionally, implementing their new ACP
skills can lead to stronger patient-provider relation-
ships, a more positive work environment, and ulti-
mately more well-being among healthcare
professionals.43 Moreover, if healthcare professionals
lack these essential skills and solely rely on patients and
caregivers to address ACP and end-of-life discussions, it
could exacerbate existing disparities in healthcare.44
Prioritizing the well-being of healthcare professionals
may play a pivotal role in fortifying and enhancing
healthcare systems, subsequently benefiting the overall
health of the population. Based on this overall ratio-
nale, we aimed to systematically review the evidence on
Table 1
Detailed Inclusion and Exclusion Criteria
Inclusion Criteria
 All peer reviewed primary studies with healthcare professionals as
participants were included (no restrictions regarding work setting,
socio-demographic characteristics)
 All types of advance care planning interventions (trainings,
workshops program implementation, etc.) at any level (person,
healthcare provider, system)
 The article needed to have an outcome regarding healthcare
professionals’ well-being (articles including healthcare
professionals’ attitudes, roles, barriers and facilitators for practice
were also included since they are relevant to our broad definition of
well-being).
 No restrictions regarding language or year of publication of the
articles.
175
the impacts of ACP interventions on healthcare profes-
sionals’ well-being.
Methods
Study Design
We performed a systematic review of the literature
using the Joanna Briggs Institute (JBI) Manual for Evi-
dence Synthesis.45 The results are presented following
the PRISMA (Preferred Reporting Items for Systematic
reviews and Meta-Analyses) 2020 reporting guideline.46
The review protocol was published on July 24, 2022 in
the International Prospective Register of Systematic
Reviews PROSPERO (ID: CRD42022346354).
Eligibility Criteria
We searched for studies evaluating the impact of
ACP interventions on healthcare professionals’ well-
being. We included any type of evidence that matched
our “PICOS” criteria (Participants, Intervention, Com-
parator, Outcome, Study Design). There were no
restrictions on year of publication as we were interested
in the evolution of this field over time. Eligibility crite-
ria are detailed in Table 1.
Participants/Population. We included articles in which
the population studied consisted of fully trained health-
care or social work professionals (e.g., medical doctors,
case managers, nurses, social workers, dietitians, etc.)
in any healthcare setting (e.g., hospitals, clinics, home
care, nursing homes, etc.). Professionals in training
were not included (e.g., residents, medical students,
nursing students).
Intervention/Exposure. All types of ACP interventions
were included: ACP training, implementation of ACP
strategies, professional awareness activities regarding
ACP, ACP tool development and implementation. We
did not apply any restrictions on the level of care at
Exclusion Criteria
 Articles on advance care planning in psychiatric illnesses without a
mention of end-of-life goals of care.
 Reviews, case studies, editorials, letters, conference abstracts, books,
study protocols, theses and opinions.
 Articles with interventions focusing only on palliative care without
mention of future planning and goals of care.
 Articles concerning healthcare professionals in training (students,
residents, etc.).
176 Gomes Souza et al.
which ACP interventions could take place (i.e. patient,
health care provider, health care facility, or system
level). Articles mentioning living wills, naming of a sur-
rogate decision-maker, do-not-resuscitate or do-not-
intubate orders and dialysis decision making were only
considered if they also mentioned planning goals of
care. Our intention was to include articles that sur-
passed mere documentation of the prevalence of these
decisions within particular populations or the adher-
ence of healthcare professionals to them. Instead, we
aimed to analyze articles that focused on the underly-
ing goals and objectives of care planning associated
with these medical decisions. For example, articles dis-
cussing palliative interventions (e.g., the ethics of feed-
ing patients or using antibiotics at the end of life) or
psychiatric interventions that did not mention advance
care planning or include goals of care were excluded.
Interventions related to assisted dying and euthanasia
were not included either because they are not widely
accepted as advance care planning interventions and
are still legally and ethically controversial.
Comparator. No restrictions.
Outcomes. Our primary outcome was the impact of ACP
on healthcare professionals’ well-being. The well-being of
healthcare professionals has a broad definition that
encompasses several dimensions. For the purpose of this
review, we used the definition coined by Brady et al.,10
which considers well-being as the capacity for healthcare
professionals to thrive, achieve their utmost potential,
and positively impact both themselves and the organiza-
tions they serve.11 To effectively operationalize our litera-
ture search on this multifaceted concept, we
incorporated a range of dimensions pertaining to well-
being as identified in existing research.13,47 These dimen-
sions encompass burnout, job satisfaction, work engage-
ment, job distress, job-related depression, job-related
anxiety, quality of life, absenteeism, distress, emotional
health, as well as professional fulfillment and satisfaction.
Nevertheless, there exists no universally accepted mea-
sure for well-being or any of these related dimensions, pri-
marily due to their overlapping nature. This compelled
us to maintain a broad scope for our outcome measures.
All the definitions used for each of those dimensions are
detailed in Supplemental material 1.
At the same time, well-being is a complex concept, as
emphasized by Chari et al.,48 and evaluating it compre-
hensively requires consideration not only of its various
dimensions but also of the subjective factors that pro-
vide indirect insights into one’s well-being. In our sys-
tematic review, we incorporated three secondary
outcomes intricately tied to well-being, as they exert sig-
nificant influence on it, namely: 1) the influence of
ACP on healthcare professionals’ attitudes, including
perception of confidence, competence, and
Vol. 67 No. 2 February 2024
knowledge, and both positive and negative perceptions
towards patients or towards their own practice.49 For
example, whether healthcare professionals expressed
an increase in empathy, understanding, and compas-
sion towards patients with whom they were to discuss
goals of care. Healthcare professionals’ perceptions
towards patients and their own practice can profoundly
affect their well-being. Positive perceptions, such as
empathy and fulfillment, may enhance job satisfaction
and motivation, ultimately contributing to a sense of
well-being. Conversely, negative perceptions could lead
to reduced job satisfaction and compassion fatigue; 2)
The influence of ACP as a barrier or facilitator to
healthcare professionals’ practice. ACP can serve as
both a facilitator, streamlining clinical practice when
supported by structured guides, and a barrier when
perceived as time-consuming or lacking necessary
resources, influencing well-being accordingly;50 and 3)
the impact of ACP interventions on healthcare profes-
sionals’ professional roles. For example, how an ACP
intervention might increase healthcare professionals’
sense of responsibility when engaging in end-of-life dis-
cussions which could improve their satisfaction with
their role and consequently their well-being.51
Study Designs. We only included primary studies pub-
lished in peer-reviewed journals. Studies could be
quantitative (e.g., randomized trials, quasi-experimen-
tal, cross-sectional) or qualitative (e.g., phenomenolog-
ical, ethnographic, qualitative descriptive) or both
(mixed methods). Reviews, case studies, editorials, let-
ters, conference abstracts, books, theses, and opinion
articles were not included.
Information Sources
A comprehensive search strategy was developed by
the research team in collaboration with an information
specialist (F.B.). An initial search strategy was launched
on April 4, 2022, and relaunched on March 6, 2023, for
the update, in the following databases: Embase
(Embase.com), CINAHL, Web of Science, and
PubMed. The search strategy was designed according
to the PICOS format. A combination of free and con-
trolled vocabularies on advance care planning, health
personnel and well-being dimensions (e.g., burnout,
job satisfaction, work engagement, job distress, job-
related depression, job-related anxiety, quality of life,
absenteeism, distress, emotional health, as well as pro-
fessional fulfillment and satisfaction) were used for the
literature search. The complete search strategy is avail-
able in Supplemental material 2.
Selection Process
After the database search, the articles found were
imported and stored in EndNote X9 (version X9, 2018,
Clarivate Analytics) for the manual removal of
Vol. 67 No. 2 February 2024 ACP Interventions on HCP’s Well-being
duplicates and management of references.52 After
manually removing duplicates, the remaining articles
were exported to Covidence (Covidence Systematic
Review Software, Australia) ensuring the removal of
any remaining duplicates by an automation tool and
enabling the selection process. We then built a selec-
tion grid based on the inclusion and exclusion criteria.
A meeting was held with the team members participat-
ing in the selection process to ensure comprehension
of all concepts and elements present in the grid. A pilot
of the selection process was performed with a random
sample of 10% of the articles.
The reviewers (L.G.S., R.C.C., D.A.B., V.R., S.G.D.,
and K.P.) screened titles and abstracts using the exclu-
sion criteria to exclude any obviously irrelevant articles
(e.g., systematic reviews, conference abstracts, articles
referring to advanced clinical practice, also known as
ACP, etc.). Articles that did not contain enough infor-
mation in their title or abstract to meet the criteria for
exclusion and articles without abstracts were retained
for full text review. Articles written in languages other
than English, French, Portuguese, or Spanish were sent
for translation and included or excluded after full-text
review. If a conflict between reviewers could not be
resolved by discussion, a third reviewer was consulted to
resolve the conflict (F.L. or P.A.). After this step, we per-
formed a full-text review. In this step, reasons for exclu-
sion included that the papers had no ACP interventions
or no interventions at all and no measures related to the
well-being of healthcare professionals. Reasons for
exclusion after full-text review were registered in Covi-
dence (details in Supplemental material 3).
Data Extraction
The extraction process was done using Covidence. A
pilot extraction was performed with 10% of the articles
to assess concordance between reviewers and to assess
if there was other useful information to be extracted.
Any disagreement between the reviewers was resolved
through discussion; if consensus was not reached, a
third reviewer was consulted to resolve the conflict.
The extraction grid developed by the research team
was discussed with a patient partner (K.K.) and a
healthcare professional representative (V.B.).
Data Items
We report on our main outcome, well-being, and our
secondary outcomes in the outcomes section. From
included articles we collected 1) bibliographic data, such
as journal name, title, main author, year of publication,
language, aim of study, study design, country,); 2) popula-
tion data, such as target population, number of partici-
pants, years of professional practice, age, sex, gender,
ethnic origin; and 3) intervention data, such as sampling
process, rurality, level of care, name of the intervention,
procedures of the intervention, patient engagement in the
177
development or implementation of the intervention, and
if the interventions were interprofessional or not. We
included the patient engagement variables because it is
vital to include patients in research, particularly in end-of-
life studies, as highlighted in existing literature.53−58 Addi-
tionally, using interprofessional approaches and interven-
tions has been suggested to ease the workload on
professionals. This approach promotes collaboration
among the different professionals, which could alleviate
individual burden and enhance overall well-being.59
Importantly, this approach is also backed by evidence on
end-of-life care.60,61
We collected socio-demographic variables, including
ethnic origin, sex, and gender, to describe the popula-
tion participating in our studies without implying any
form of discrimination. Our aim was to ensure compre-
hensive reporting of the diverse makeup of healthcare
professionals participating in the studies. More details
regarding all variables extracted and their definitions
are available in Supplemental material 1.
Quality Assessment
To assess the quality of the articles included in the
review we used the Mixed Methods Appraisal Tool
(MMAT).62 This tool can be used for evaluating the
quality of numerous study designs: qualitative research,
randomized controlled trials, nonrandomized studies,
quantitative descriptive studies, and mixed methods
studies. It includes a screening section with two ques-
tions for determining whether the article can be evalu-
ated with the tool, and a design-specific section with
five quality criteria. All the questions in the tool can be
answered with “yes,” “no” or “can’t tell.” Two reviewers
separately analyzed the scores on each MMAT criterion
to better report on the quality of the included studies.
When a disagreement could not be resolved by discus-
sion, a third senior researcher was consulted to resolve
the issue. We were unable to perform a GRADE63 cer-
tainty assessment in our systematic review due to the
heterogeneity of the included studies, which varied sig-
nificantly in terms of population, interventions, and
outcomes.
Synthesis Methods
To describe the study selection process, we used the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) flow diagram.46 We used
tables to describe characteristics of included studies
such as the first author’s name, year of publication,
study design and main results. We grouped articles into
qualitative or quantitative studies. Due to the wide vari-
ety of study designs and outcomes included in this
review, we did not conduct a meta-analysis. For the
qualitative data, we conducted an inductive thematic
synthesis of findings.64 To perform the thematic synthe-
sis, we developed a codebook comprising codes derived
178 Gomes Souza et al.
Fig. 1. Flowchart of included studies.46
from the data. Coding was carried out by the first
reviewer (L.G.S.) and checked by a second reviewer
(R.C.C.), both with experience in qualitative analyses.
Disparities in coding were resolved by consensus with a
third party. Codes were regrouped into descriptive
themes that captured and described patterns in the
data across studies.65 We present our findings in the
form of a narrative synthesis for both the quantitative
and qualitative data.
Results
Article Search and Selection
Our electronic search identified 8235 potentially rel-
evant records. After the exclusion of duplicates, 5328
articles were retained for title and abstract screening.
The research team could not retrieve four of the
articles and the contact information of their authors
was not available. Full texts of 889 articles were assessed
for eligibility. After applying our inclusion/exclusion
criteria, we included 21 articles. Fig. 1 shows the
PRISMA flowchart.
Vol. 67 No. 2 February 2024
Article Characteristics
The articles included in this review were only in
English and published between 1997 and 2022, most of
them after 2019 (n = 17). They were conducted in nine
countries: Australia (n = 5), Canada (n = 5), United
States (n = 4), United Kingdom (n = 2), Norway
(n = 1), Switzerland (n = 1), Ireland (n = 1), Nether-
lands (n = 1), and Singapore (n = 1). Out of the 21 stud-
ies, 11 used a qualitative approach, seven used a
quantitative approach, and three were mixed methods.
In the studies that used a quantitative approach
(n = 7), only one was a randomized trial (Table 2).
Quality Analysis
According to the MMAT criteria,62 most of the stud-
ies using a qualitative methodology took an appropri-
ate approach to addressing the research question
(n = 10) and used a suitable qualitative data collection
method (n = 12). However, in a significant number of
articles the interpretation of the results was not sup-
ported by the data (n = 7) (Figure 2).
In contrast, all the included studies using a quantita-
tive methodology had methodological flaws (Figure 2).
Vol. 67 No. 2 February 2024 ACP Interventions on HCP’s Well-being 179

Table 2 Intervention Characteristics

Article Characteristics Studies included in this systematic review and their
Author Year Country Study Design interventions were conducted in four different care set-
Aasmul 2019 Norway Cluster randomized trial
tings. Six studies were conducted each in long-term
Barra 2021 USA Descriptive qualitative care, primary care, and tertiary care settings, while four
Boyd 2010 UK Mixed methods were conducted in secondary care (e.g., specialized
Crowley 2022 Ireland Cross-sectional
Davis 2019 Australia Descriptive qualitative
outpatient care). Most of the interventions (n = 11)
Detering 2014 Australia Before-after occurred in urban settings. The Serious Illness Care
Fortin 2021 Canada Descriptive qualitative Program (SICP) was the most frequently studied inter-
Groenewoud 2021 Netherlands Before-after
Hafid 2021 Canada Mixed methods
vention, appearing in four studies, while the other
Hendry 2022 UK Descriptive qualitative interventions only appeared once each. Two studies
Korman 2020 Canada Descriptive qualitative reported the engagement of patient partners in their
Lagrotteria 2021 Canada Descriptive qualitative
Molloy 1997 Canada Before-after
interventions (Supplemental material 5).
Morgan 2021 Australia Descriptive qualitative Regarding intervention characteristics, most studies
Ohr 2021 Australia Descriptive qualitative (n = 16) involved training, (e.g., workshops, conferen-
Paladino 2020 USA Cross-sectional
Paladino 2021 USA Descriptive qualitative
ces), while eight used knowledge tools (e.g., guides,
Patel 2020 USA Descriptive qualitative assessment tools, toolkits) and eight implemented a
Smith 2017 Australia Mixed methods program (e.g., an organized multitarget intervention).
Sommer 2021 Switzerland Descriptive qualitative
Yu 2021 Singapore Longitudinal (pre-post and
Additionally, most interventions were considered com-
6-month follow-up) plex (n = 14). For the purposes of this review, we con-
sidered a complex intervention as an integrated care
approach that combines two or more prevention strate-
gies on at least two different levels of care: patient,
For example, authors of the only randomized clinical healthcare provider and/or health care system66 (Sup-
trial19 were unable to ensure an adequate randomiza- plemental material 3). Varied teams of experts, both
tion and did not indicate whether there was complete from healthcare and other fields, delivered the ACP
outcome data, whether the outcome assessors were interventions. Teams included professionals such as
blinded, or whether the participants adhered to the ethicists, physicians, nurses, palliative care specialists,
intervention. Authors of none of the nonrandomized and ACP experts. Nurses were the most frequent
quantitative studies were able to report whether the group delivering interventions. Most interventions
study participants were representative, or if confound- included training initiatives aimed at equipping
ing factors were considered.21,24,26,27,31,37,39 Only two healthcare professionals with the skills required for
studies used appropriate measures and reported com- conducting ACP discussions. It is worth noting that
plete outcome data.27,37 However, authors of most of these training efforts exhibited considerable diversity
the nonrandomized quantitative studies (n = 6) admin- in their methodologies and approaches. The timing
istered the intervention as planned.21,24,26,27,31,39 Of and dosage of the interventions also showed varia-
the two quantitative descriptive studies, one met one of tion across studies, with each intervention employing
the five MMAT criteria (a relevant sampling strategy),22 distinct strategies to engage participants, varying in
while the other met two: report a low risk of nonre- duration, and incorporating pedagogical elements
sponse bias and an appropriate statistical analysis.35 such as reinforcement. More details concerning the
Finally, most of the mixed methods studies had major delivery of these interventions are available in sup-
flaws in all MMAT criteria.21,27,37 plementary material 5. Finally, while three studies
explicitly reported that their intervention was inter-
professional (n = 3), most studies did not report
Participant Characteristics whether their interventions were interprofessional
The systematic review included a total of 1278 or not (n = 9) (Supplemental material 5).
healthcare professionals across multiple studies. The
profession most frequently represented was nursing,
with 16 studies including nurses, followed by physicians Impact of ACP Interventions on Healthcare
with 13 studies and social workers with seven studies. Professionals’ Well-Being
Most participants were female and over 40 years old The only randomized clinical trial19 included in this
(Supplemental material 4). Despite our intention to review showed a statistically significant reduction in
collect sex and gender variables separately, the authors’ stress levels four months after the intervention (ß= -1.8;
lack of clarity in defining and differentiating between 95% CI: -3.1, -0.4; P < 0.05). However, the reduction
sex and gender forced us to combine “sex or gender” was no longer statistically significant at nine months
into a single variable. (ß=-1.5; 95% CI: -3.3, 0.3 P > 0.05). Similarly, the only
180 Gomes Souza et al. Vol. 67 No. 2 February 2024

Fig. 2. Quality analysis of the included studies based on the MMAT criteria.62

longitudinal study with a before-after evaluation and
six-month follow-up39 demonstrated that professionals
experienced a significant positive change in their belief
that ACP is a pleasant experience for themselves imme-
diately after ACP training, but this change decreased
after six months. The study also found that professio-
nals did not experience a significant change in their
perception that ACP was emotionally draining, neither
right after the ACP training nor six months later. In
contrast, another before-after study conducted by
Detering et al.24 indicated that after receiving training,
fewer clinicians considered that helping patients com-
plete an advance directive (AD) was emotionally drain-
ing. The other quantitative studies included also
seemed to indicate that the ACP interventions had a
positive effect (Table 3).
Analysis of our qualitative data identified two
themes related to healthcare professionals’ well-
Vol. 67 No. 2 February 2024 ACP Interventions on HCP’s Well-being 181

being. First, ACP interventions increased work satis- theme, which appeared five times in different
faction among healthcare professionals (10 different articles, indicated a negative impact on well-being
studies mention the theme). However, the other by suggesting that ACP interventions can be

Table 3
Summary of Quantitative Study Outcomes
Primary Outcome: Healthcare Professionals’ Well-Being
Author Year Study Design Name of the Measurement Association Measure/ Outcome
Tool Frequency

Aasmul 2019 Cluster randomized trial Neuropsychiatric Inventory  Four months: B= 1.8 There was a reduction in
Nursing Home Version (95% CIa: 3.1, 0.4) P < stress levels four months
(0−60) 0.05b after the intervention, but
 Nine months: B= 1.5 (95% this was no longer
CIa: 3.3, 0.3) P > 0.05b statistically significant at
nine months.
Detering 2014 Before-after Attitudes and confidence  Mean difference between ‘Helping patients complete
towards ACP (Likert pre and post P = 0.02b an Advance Care Plan is
scale: 1−4: Strongly agree emotionally draining,’
to strongly disagree) with fewer doctors
considering this to be
emotionally draining
following education.
Groenewoud 2021 Partially controlled Adapted Patz-list (scale not  Intervention: 16.2% The intervention group did
before-after reported)  Comparison: 12.7% not have more tension
 P-value= 0.570b because they discussed
death proactively.
Paladino 2020 Cross-sectional Not specified (Likert-scale:  50% of professionals said
1−5: much worse to much the guide decreased their Most clinicians said the
better) anxiety about end-of-life guide decreased their
discussions anxiety about end-of-life
discussions.

Yu 2021 Longitudinal (pre-post and Not specified (Likert-scale:  Mean difference: pre vs. The professionals did not
6- month follow-up) 1=strongly disagree to 4 post 0.03 (95% CIa: have a significant change
=strongly agree) 0.13; 0.19) P-Value: in their perception that
1.00a,b ACP was emotionally
 Post vs. follow-up 0.09 draining right after the
(95% CI: 0.07; 0.25) P- ACP training or six
Value: 0.55b months after the training.
 Mean difference: pre vs. The professionals had a
post 0.42 (95% CI:0.27; significant positive
0.58) P-Value: <0.01a,b change in their belief that
 and Post vs. follow-up ACP is a pleasant
0.19 (95% CIa: 0.35; experience for themselves
0.03) P-Value: 0.01b right after ACP training,
however these changes
decreased after six
months.
Secondary Outcome: Barriers and Facilitators
Crowley 2022 Cross-sectional Not specified (5-point  78.7% agreed The majority of
nonspecified Likert-scale)  6.5% disagreed and respondents agreed that
 14.8% were neutral advance health care
directives are helpful
when making treatment
decisions for
incapacitated patients.
Molloy 1997 Before-after Attitudes questionnaire  62.1% strongly agreed Most participants strongly
(Likert scale 1−5: strongly agreed that advance
disagree to strongly directives can make the
agree) decision-making process
for health providers
easier by informing them
of patients’ and families’
wishes.
Secondary Outcome: Healthcare Professionals’ Roles
Paladino 2020 Cross-sectional Not specified (Likert-scale:  49% of professionals had 49% of clinicians said their
1−5: an increase in satisfaction satisfaction with their role
greatly decreased to greatly with their role in patient care increased
increased) slightly.
a
95% CI: confidence interval at 95%.
b
P-value in bold: statistically significant (P-Value< 0.05).
182
Codes Generated From the Qualitative Analysis and Their Frequency
Codes Generated
Well-Being
An ACP intervention increases the satisfaction with their work among professionals.
An ACP intervention can be frightening and worrisome
Attitudes
An ACP intervention improves healthcare professionals’ attitudes towards their
practice (perception of confidence, competence, and knowledge)
An ACP intervention improves attitudes toward patients
a
Number of times mentioned across unique studies.
frightening and worrisome for professionals (Table 4
and Supplemental material 6).
Impact of ACP on Healthcare Professionals’ Attitudes
Only qualitative studies evaluated the impact of ACP
on healthcare professionals’ attitudes. The included
ACP interventions appeared to improve healthcare pro-
fessionals’ attitudes towards their practice by increasing
their confidence, competence, and knowledge (men-
tioned eight times). At the same time, ACP also fostered
better attitudes towards patients (mentioned eight
times). (Table 4 and supplemental material 6).
ACP as Barrier or Facilitator for Healthcare
Professionals’ Practice and Professional Role
Two observational studies22,31 suggested that ACP
can facilitate healthcare professionals’ practice. In
these studies, most healthcare professionals agreed
that advance directives are helpful when making treat-
ment decisions for incapacitated patients. ADs can also
make the decision-making process easier for healthcare
providers by informing them of patients’ and families’
wishes. Similarly, the single study that explored the
impact of ACP on professional roles showed it had a
positive impact on healthcare professionals’ satisfaction
with their role after the intervention35 (Table 3).
Discussion
Our systematic review aimed to synthesize the evi-
dence on the impact of ACP interventions on health-
care professionals’ well-being. We identified a total of
21 eligible studies. Most were published after 2019 and
all were published in high-income countries. Only one
study was a randomized clinical trial, in which health-
care professionals’ well-being was a secondary out-
come. Additionally, the sole randomized trial displayed
significant methodological flaws, which limits the cer-
tainty of its results. Moreover, although most studies
seemed to show that ACP has a beneficial effect on
healthcare professionals’ well-being, some qualitative
studies indicated that there may be negative impacts
(e.g., ACP being frightening and worrisome for health-
care professionals), and longitudinal measures
Gomes Souza et al. Vol. 67 No. 2 February 2024
Table 4
Number of Times the Theme
Appeared in the Articlesa
10
5
8
8
revealed that the positive effects are not sustained over
time. Regarding our secondary outcomes, only one
study seemed to demonstrate a positive effect of ACP
interventions on practitioner satisfaction with their
role and only two studies indicated ACP was a facilitator
in clinical practice. All quantitative studies analyzing
our secondary outcomes also exhibited important
methodological shortcomings. Finally, most articles did
not report on interprofessional interventions or
include patient partners in the design or implementa-
tion of their interventions. Overall, notwithstanding
the urgent need to conduct well-designed and more
robust studies whose primary outcome is the well-being
of healthcare professionals, our findings offer a
glimpse into the developing trends and potential sig-
nals in the field. Our results led us to make the follow-
ing observations:
First, our systematic review highlights a gap in high-
quality studies evaluating the impact of ACP interven-
tions on the well-being of healthcare professionals.
However, the public health literature suggests that
interventions or approaches that prioritize the well-
being of professionals have a positive impact on the
health of professionals and on healthcare system
performance.7,8,67 This is particularly important in the
case of ACP, given the emotionally charged nature of
end-of-life discussion.68,69 Hence, future ACP interven-
tions may need to equip healthcare professionals with
the necessary knowledge, tools and skills to engage in
end-of-life discussions without compromising their job
satisfaction or emotional well-being. To back this up
with evidence, it is also crucial to enhance the method-
ological rigor of studies in this area and adhere to
reporting guidelines when reporting interventions and
results.70
Second, although the quantitative studies included
did not use similar interventions or measurement
instruments, collectively they suggest that ACP has a
possible positive impact on healthcare professionals’
well-being. This observation is further supported by the
results of qualitative studies included in our review.
However, the lack of high-quality studies limits the
interpretation of the results found. In parallel, some of
the qualitative studies highlighted the potential for
Vol. 67 No. 2 February 2024 ACP Interventions on HCP’s Well-being
ACP to be frightening and worrisome for some health-
care professionals, findings that are similar in studies
implementing innovations related to other sensitive
and complex issues.71 This suggests the need for
future interventions to explore and address the
potentially negative impacts of ACP and to assess
their magnitude. Furthermore, the two articles that
used longitudinal measures demonstrated that the
positive effects of ACP interventions were not sus-
tained over time. This highlights the challenge of
maintaining changes of practice in large healthcare
systems over the long term, a challenge not specific
to ACP interventions.72−75 Future studies should
develop interventions that incorporate strategies for
sustaining changes, managing disruptions, and
adapting to the shifting priorities that are common
in healthcare systems. Such strategies could focus on
changing the culture of the healthcare system to
better integrate ACP, continuous leadership support
and continuous training and professional develop-
ment.
Third, our systematic review found only one study
suggesting a possible positive effect of ACP interven-
tions on practitioner satisfaction with their role and
only two studies indicating ACP was a potential facilita-
tor in clinical practice, none of which demonstrated
high methodological rigor. It is important to consider
practitioner satisfaction alongside patient satisfaction,
as improved practitioner satisfaction has been linked to
better patient outcomes and quality of care.76,77 Our
findings underscore the need for further research on
the impact of ACP interventions on practitioner satis-
faction and the potential indirect effects on patient out-
comes. Similarly, there is a dearth of research
examining ACP interventions as potential facilitators
or barriers to professional practice (e.g., ACP interven-
tions increasing or reducing the number of tasks a
nurse is responsible for or helping to streamline the
routine of a medical doctor in a specific setting). Inter-
ventions that focus on improving professional practice
have proven positive in other fields.78,79 Thus, future
interventions should focus on designing and testing
ACP interventions that also optimize and support pro-
fessional practice, as this can lead to improved health-
care professional well-being as well as improved patient
outcomes and satisfaction.
Fourth, 17 of the 21 articles included in this review
were published after 2019, indicating that ACP has
become a pressing issue among healthcare professio-
nals and healthcare systems. A bibliometric analysis of
publications on ACP has shown a similar trend, with an
increase in the number of publications related to ACP
in the last decade.80 This trend became even more evi-
dent after the pandemic due to the severe impacts of
COVID-19 on the elderly and frail. ACP discussions
could prevent unwanted hospitalizations for this
183
population,81 alleviating the additional strain on
resources caused by the pandemic. Also, all included
articles were published in high-income countries, a
trend that was also noted in the aforementioned biblio-
metric analysis.80 The lack of studies on ACP per-
formed in low- and middle-income countries could be
attributed to a lack of financial support to sustain such
programs as well as cultural beliefs surrounding death,
as shown in other end-of-life care studies.82−84 Low-
and-middle-income countries have extensive expertise
in implementing and scaling up other health interven-
tions.85 Therefore, implementing and scaling ACP in
these contexts would provide further scientific knowl-
edge about ACP and contribute to a global assessment
of the impact of ACP on the well-being of professionals.
Moreover, exploring the psychological burden and the
job satisfaction of healthcare professionals engaging in
ACP in diverse contexts would provide information on
a wider variety of coping mechanisms and help develop
more effective support systems. Studies could also allow
us to identify best practices and policy implications,
leading to the spread of ACP that is adapted to cultural
and contextual differences. Ultimately, this research
could contribute to creating more supportive and ful-
filling work environments for healthcare professionals
worldwide, enhancing their ability to navigate complex
end-of-life conversations. It is thus crucial to expand
interventions and implement them in diverse contexts
such as low-and-middle income countries.
Finally, our systematic review highlighted that there
is a scarcity of interventions that incorporate an inter-
professional model of ACP and/or engage patients as
partners in the development, implementation, or coor-
dination of interventions. Interprofessional collabora-
tion is widely recognized as an essential aspect of
delivering effective patient-centered care, and at the
same time it seems to have a positive impact on health-
care professionals’ well-being and job satisfaction.86−88
An interprofessional approach can help relieve the
burden of ACP on healthcare professionals by the shar-
ing of tasks, the joint discussion of complex cases, and
distribution of the workload among more healthcare
professionals with broader experience and knowl-
edge.89 There may thus be opportunities for improving
the quality of ACP interventions by leveraging the
unique perspectives and expertise of a more diverse
group of healthcare professionals. Also, engaging
patients in healthcare interventions results in interven-
tions that are more focused on meeting patient needs
and preferences.90 When healthcare professionals
deliver patient-oriented interventions, they become
better equipped to address the patient’s unique needs,
leading to increased job satisfaction, fulfillment and
better attitudes towards patients.91 Therefore, future
research should focus on developing and testing ACP
interventions that utilize an interprofessional approach
184 Gomes Souza et al.
and involve patient partners to create interventions
that are both effective and relevant to the needs and
preferences of patients and families.
Limitations
This systematic review is the first to address the knowl-
edge gap related to the impact of ACP interventions on
the well-being of healthcare professionals, and despite its
methodological rigor some possible limitations need to
be acknowledged. The first was the heterogeneity of the
studies included. Due to differences in study design, par-
ticipants, interventions, and outcomes, it was difficult to
compare the results of all the studies and draw overall
conclusions. It was necessary for us to group certain pro-
fessions in order to conduct our analysis. In addition,
the roles played by these professions in ACP can vary sig-
nificantly based on their job titles and the countries they
practice in. For example, advanced nurse practitioners
and registered nurses fulfill different roles in different
countries when it comes to ACP and end-of-life discus-
sions. Moreover, the variability in measurement tools
and outcome definitions among the studies prevented
us from conducting a meta-analysis to estimate an overall
effect. Another significant limitation was the quality of
the included studies, which varied considerably in terms
of rigor and reliability. Our study highlights a need to
conduct more systematic and rigorous studies of evi-
dence-based ACP interventions to explore the well-being
of healthcare professionals.
Conclusion
To the best of our knowledge this is the first system-
atic review to explore the impact of ACP interventions
on the well-being of healthcare professionals. Most of
the existing literature we were able to identify points to
ACP interventions having a positive impact on the well-
being of healthcare professionals. However, given the
scarcity of high-quality studies assessing this impact as a
primary outcome of interest, we cannot provide at a
definitive conclusion and urgently invite future trials in
this area. Indeed, some included qualitative studies
seemed to indicate that ACP could be distressing for
healthcare professionals, and thus emphasize the need
to further explore this potential negative impact on
healthcare professionals’ well-being. Similarly, longitu-
dinal studies demonstrated that the potential positive
effects of ACP interventions diminish over time, under-
scoring the necessity for strategies that sustain changes
and adapt to evolving healthcare priorities.
Data Sharing Statement
Data are available upon reasonable request.
Vol. 67 No. 2 February 2024
Disclosures and Acknowledgments
The authors acknowledge the work of Louisa Blair
for her editorial help with the manuscript and Karine
Plourde (KP) for her vital help in the selection steps.
The authors thank PCORI and the members of the
Meta-LARC ACP trial team for inspiring this project.
FL holds the Tier 1 Canada Research Chair in
Shared Decision Making and Knowledge Translation.
LGS received the scholarship Fonds strategique de
developpement de la recherche from VITAM-centre
de recherche en sante durable. The financial providers
had no role in the collection, analysis and interpreta-
tion of data; in the writing of the report and in the deci-
sion to submit the article for publication. The authors
have no conflicts of interest to declare.
Supplementary materials
Supplementary material associated with this article
can be found, in the online version, at doi:10.1016/j.
jpainsymman.2023.09.026.
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