A cross-sectional survey was employed in the current study.

Of the 14,439 home care support clinics registered nationwide as clinics with a track record of home visits, house calls, and end-of-life care, 1444 clinics, or 10%, were randomly selected to be the survey subjects.

The questions were created independently through discussion among researchers with the aim of clarifying the awareness of ACP, its implementation status, and the issues that need to be overcome in order to implement it in home care support clinics across the country. In order to obtain responses from as many clinics as possible, we considered questions that could be answered concisely without interfering with work, and decided on a total of 30 items. The main content included basic data (age, occupation, clinic classification, whether or not home visits/house calls were conducted, number of years they were conducted, and details of implementation), knowledge of ACP (awareness, experience participating in training), implementation status of ACP (whether or not it was conducted, number of years it was conducted, time required per session), requirements considered necessary for implementing and continuing ACP, and difficulties and benefits of implementing ACP. The survey questionnaire was created by researchers after consulting specialized books on social research and questionnaire surveys [14] - [16] , and after undergoing a pre-test, the final survey questionnaire was completed (See Appendix).

A survey request form was sent by mail, and facility representatives who agreed were asked to complete an online survey using Google Forms to collect the data. The survey period was from July to August 31, 2023. The reason for choosing a web survey was to reduce the resistance to cooperation in answering the survey, as many clinics are busy. In addition, the results of the survey were analyzed early on, in order to proceed with the next step of this research, which is to develop an ACP support program in the field of primary care in Japan.

Basic data and knowledge and implementation status of ACP were simply tallied for each item. Items that asked for free-form responses were analyzed in accordance with Berelson B.’s content analysis [17] introduced by Funashima (2007), to maintain objectivity and avoid the analyst’s subjectivity or bias. All written content was systematically analyzed, and classified and categorized according to the written language and its similarity of meaning.

Approval was obtained from the ethical review committee of the affiliated institution (approval number: 2023-9-A). After indicating ethical considerations in the survey request, such as anonymity, strict adherence to information management, and voluntary participation, responses to the survey were deemed to have given consent for research cooperation.

The demographics of participants and their affiliated clinics are shown in Table 1 . The largest group was those in their 50s with 33 people (33%) and doctors with 79 people (71.2%). Regarding the classification of clinics, 103 (92.8%) were clinics without beds, and 108 (97.3%) were clinics that provided home visits or house calls. The largest number of clinics, 66 (61.1%), have been conducting home visits and house calls for more than 10 years ( Table 1 ), and Many of the reasons given for the implementation of ACP were the needs of the residents, a sense of role and satisfaction in contributing to community health care, and succession from the predecessor.

In terms of facility staffing, the majority of facilities had a single doctor (46 people, 46.8%). For nurses, 26 facilities (23.4%) had six or more nurses, followed by around 15% with 1 - 5 nurses. Around 80% had no therapists such as social workers, caregivers, or physical therapists, and the proportion of administrative staff was similar to that of nurse ( Table 1 ).

Knowledge and interest in ACP were shown in Table 2(a) . Forty-seven people (42.3%) were familiar with ACP, 47 people (42.3%) knew about it, 10 people (9.0%) had heard of it but were not familiar with it, and 6 people (5.4%) did not know of it, meaning that 84.6% of people were familiar with it or knew about it. Regarding experience of participating in ACP-related training or programs at conferences, 69 respondents (62.1%) and/or facility staff had participated, while 42 respondents (37.8%) had not.

ACP implementation status was shown in Table 2(b) . Fifty-five people (49.5%) were taking the initiative in implementing ACP, 18 people (16.2%) were involved in ACP but not the initiative, 10 people (9%) were considering it, and 28 people (25.2%) had not implemented ACP. Of the 73 people who were implementing or involved in ACP, the highest number of years was 33 people (45.2%) who had been implementing ACP for 5 years or more, followed by 22 people (30.1%) who had been implementing ACP for 1 - 3 years ( Table 2(b) ). Regarding the monthly number of ACP implementations, 44 people (60.3%) had 20 cases or more ACPs, followed by 10 people (13.7%) with 5 - 10 cases or less, and 7 people (9.6%) with 10 - 20 cases or more. In the case of short sessions, the time required for each ACP session was 5 minutes or less in 24 people (32.9%), 10 minutes in 23 people (31.5%), 20 minutes in 14 people (19.2%), 30 minutes in 9 people (12.3%), and 60 minutes or more in 2 people (2.7%). In the case of longer sessions, the time required for each ACP session was 30 minutes in 29 people (39.7%), and 60 minutes or more in 22 people (30.1%), followed by 20 minutes in 13 people (17.8%), 10 minutes in 6 people (8.2%), and 40 minutes in 2 people (2.7%).

We asked 73 people who are implementing or involved in ACP to respond. The priorities for the requirements for implementing and continuing ACP were, in order, “Knowledge and information about ACP”, “Understanding of those involved (patients and families)”, and “Cooperators within the facility (people who understand)” ( Figure 1 ). Similarly, 28 people who answered that they had not implemented ACP or were considering it were asked about the factors necessary for implementing ACP. The highest priorities were “Knowledge and information about ACP”, “Understanding of those involved (patients and families)”, “Time”, and “Cooperators within the facility (people who understand)”.

Difficulties in implementing ACP were shown in Table 3 . Nine categories (indicated in brackets [ ]) and 23 subcategories (indicated in brackets < >) were generated from the written responses obtained from 48 participants.

The researchers discussed the matter repeatedly in order to improve the validity of the study. As a result, the following three issues emerged from the categories that were generated.

<Not established as a system> and <Not included in medical treatment fees>, [Low convenience and lack of common tools] has three subcategories: <Need for tools>, <Lack of standardized tools>, and <Convenience of online management, etc.>, [Low awareness of ACP] has two subcategories: <Not recognized in society> and <Publicity activities conducted but not implemented>, and [Negative feelings toward preparations for and discussion of death] has three subcategories: <Taboo consciousness regarding the topic of death>, <Unable to face death>, and <Unable to imagine the future>.

[The patient/family is not interested in or understands ACP] consists of two subcategories: <gaining the patient/family’s understanding> and <the patient/family is not very interested>. [The patient/family cannot agree on their opinion] consists of three subcategories: <the patient/family’s wishes cannot be confirmed>, <the patient/family cannot agree on their opinion> and <opinions change depending on the person or situation>.

[Lack of knowledge, skills, and experience among medical professionals] consists of four subcategories: <Difficulties in knowledge and understanding among medical professionals>, <Lack of interview skills among medical professionals>, <Building relationships with the patient and their family>, and <Difficulty in responding to each case>. [Timing of introduction and implementation during intervention] consists of two subcategories: <Determining which targets need to be introduced> and <Implementation according to the illness or condition>. [Securing time and adjusting schedules] consists of two subcategories: <Adjusting time> and <Securing time>.

Benefits of implementing ACP were shown in Table 4 . Six categories (indicated in brackets [ ]) and 21 subcategories (indicated in brackets < >) were generated from the written responses obtained from 41 participants. The researchers discussed the matter repeatedly in order to improve the validity of the study. As a result, the following three elements emerged from the categories that were generated, which led to the resolution of the three issues mentioned above.

[It provides an opportunity for the patient, their family, and medical professionals to confirm their wishes] is made up of three subcategories: <facing the patient’s wishes>, <being able to confirm one’s own wishes>, and <feeling at ease when expressing one’s own wishes>. [Family and related parties gain a deeper understanding of the patient and reach an agreement] is made up of two subcategories: <family and staff gain a deeper understanding of the patient> and <everyone is able to reach a consensus>.

[Able to respond in a way that respects the patient’s wishes, both in normal times and in emergencies] consists of three subcategories: <Able to have a common understanding and respect the patient’s wishes>, <Able to utilize this in determining future policies at the hospital>, and <Able to respond smoothly in an emergency based on the patient’s wishes>. [Able to provide satisfactory end-of-life care for the family based on the patient’s wishes] consists of three subcategories: <Family members can provide end-of-life care by understanding the patient’s wishes >, <Satisfying end-of-life care>, and <Able to provide end-of-life care at home and the family is pleased>. [Able to remain at peace even after the family’s final moments] consists of three subcategories: <The patient and family were able to spend the final days peacefully>, <Peace of mind for the family>, and <Final letter to the family>.

[Leading to improved awareness, knowledge and experience among medical professionals] consists of seven categories: <It is almost always done in the terminal stage>, <It is very important in terms of consideration and communication>, <Awareness of providing sufficient explanations>, <Experience of staff>, <Knowing that life does not always go as planned>, <Clarified policy> and <No need to call the police>.

Training of implementers is underway, including the suitability of social workers and visiting nurses as ACP implementers [18] [19] and the effectiveness of ACP implementation by ACP facilitators [20] .

However, the primary care field is busy, requiring a wide range of roles from preventive medical care to end-of-life care for residents [21] . The results of this study showed that while 97.3% of clinics carried out home visits and house calls ( Table 1 ) in addition to regular clinical duties, the staffing ratio of each clinic ranged from 1 to a maximum of 6 nurses, and around 60% of clinics did not employ social workers. This means that the burden on the doctors and nurses who are the main caregivers is considerable when it comes to carrying out ACP in addition to their regular duties, including home visits and house calls. As for [not institutionalized], the fact that <it is not institutionalized in medical fees> not only means that implementing ACP is given a low priority within work ( Table 3 , C1), but it does not reduce the burden on each staff member and they do not have the time to do so, which is thought to be an influence on the result that only 69 people (62.1%) had experience participating in ACP-related training or programs at conferences ( Table 2(a) ). When asked what is necessary to implement and continue ACP, the most common answer was “knowledge and information about ACP implementation” ( Figure 1 ). Because it is difficult to find the time, despite feeling the need ( Table 3 , C12), we think that setting up a learning environment through online formats and e-learning, etc. [22] [23] , as well as participating in training sessions and academic conferences, would be effective in promoting the implementation of ACP. In addition, there are opinions calling for convenience such as a common format and online management ( Table 3 , C2, C3), but [the lack of convenience and common tools] is putting a burden on the work. In order to improve convenience, attempts have been made to develop interactive websites, which are useful for understanding ACP and sharing information among those involved, but there are issues regarding the promotion of discussions among those involved, such as the use of online functions [24] . Based on the Ministry of Health, Labor and Welfare’s Life Conference [18] , each prefecture and municipality has created its own record sheets for ACP tools. In addition, there are a variety of tools that emphasize ease of use for those involved, such as ACP implementation tools for target patients and ACP tools by companies, along with explanations of treatment and pathological progression by disease by medical institutions. Based on the Ministry of Health, Labor and Welfare’s Life Insurance Conference [25] , each prefecture and municipality has created its own record sheets for ACP tools. In addition, there are a variety of tools that emphasize ease of use for those involved, such as ACP implementation tools for target patients and ACP tools by companies, along with explanations of treatment and pathological progression by disease by medical institutions. To promote widespread adoption and implementation, ease of use for medical professionals will also be important.

When implementing ACP, there are many problems, such as patients lacking basic knowledge ( Table 3 , C4) and a low sense of involvement ( Table 3 , C5). Difficulties were felt in [a lack of interest or understanding in ACP from patients and their families], and the public awareness is still low [9] . Similarly, in the primary care domain, we feel that patients and families have [a low awareness of ACP], and it is difficult for medical professionals to have opportunities to discuss it due to [preparations for death and negative feelings towards the topic]. It turns out that.

What makes it difficult to deal with this issue is that [the opinions of the individual and their family cannot be determined], such as: <The wishes of the individual and their family cannot be confirmed>, <The individual and their family do not agree on anything>, and <Opinions change depending on the person and situation>.

On the other hand, the positive aspects of implementing ACP include the fact that it allows the patient to sort out their feelings and have them known, which brings relief ( Table 4 , D2), and that by <facing the person> through discussion, it allows them to think about things they had never considered before ( Table 4 , D1) [providing an opportunity for the patient, their family, and medical professionals to confirm their wishes].

Even when the patient and family are not ready to have a discussion, it is believed that medical professionals can provide opportunities for discussion and hold multiple meetings, which will lead to <family and staff gaining a deeper understanding of the patient> ( Table 4 , D3), and [family and other related parties gaining a deeper understanding of the patient and reaching an agreement].

They felt there were difficulties with [a lack of knowledge, skills, and experience on the part of medical professionals] such as <a lack of interview skills on the part of medical professionals> and <building relationships with the patient and their family> as well as difficulties with <the timing of implementation during introduction and intervention>. In terms of the requirements considered necessary for implementing and continuing ACP, [knowledge and information on implementing ACP] was given the highest priority, followed by [support from experts] at the lowest ( Figure 1 ).

ACP implementers are expected to be skilled medical and care providers who work with patients, their families, and other relevant parties to facilitate person-centered expression of wishes and dialogue for decision-making in order to realize medical and care decisions that are in line with the patient’s values and wishes [26] [27] . However, it was apparent that there is a need for interview skills in implementing ACP ( Table 3 , C6, C7), and that in addition to knowledge and information about ACP, there is a need for support in the form of advice and consultation at a concrete practical level.

Regarding [securing time and adjusting schedules] for implementing ACP, the time required for each ACP session is adjusted according to the situation, in the long case with 60% of sessions lasting at most 30 - 90 minutes or more and in the short case with 60% of sessions lasting 5 - 10 minutes or less. However, there is not enough time to implement it for all necessary targets ( Table 3 , C11), and it is difficult to schedule and implement stakeholder meetings at the necessary times ( Table 3 , C8, C9, C10).

Because ACP interviews are based on communication skills, it is not easy to master the skills by simply acquiring knowledge through training, etc. It is therefore advisable to receive practical training and feedback, including role-playing. However, in the field of primary care, it is difficult to find time for training while performing regular duties. Therefore, in the future, we believe it will be necessary to consider training methods that allow the time and place to be selected, such as online training, and that also include objective evaluation.