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advance care planning, communication, Delphi technique, heart failure, palliative care



  1. Kim, JinShil PhD, RN
  2. Kim, Shinmi PhD, RN
  3. Shin, Mi-Seung MD, PhD
  4. Jin, Jae Ok RN
  5. Kim, Yunmi PhD, RN
  6. Lee, Mee-Ok MSN, RN


Background: Access to consultation or referral for decisions about advance care planning (ACP) is limited, particularly for nonmalignant models pertinent to palliative care in heart failure (HF).


Objectives: The aim of this study was to solicit professional opinions about the feasibility of using an exemplary context-oriented communication algorithm for ACP discussions.


Methods: Using a panel of expert physicians and nurses in cardiovascular care, a 3-round Delphi study was conducted to evaluate the proposed model.


Results: A consensus was determined based on a content validity ratio (CVR) of 0.318 or greater, a critical value for selection of an item scored as important (>=4 on a 5-point Likert scale). A total of 50, 44, and 38 experts in Korea completed each round, respectively. Item evaluation did not differ across rounds (Friedman [chi]2 > P = .05), except for timing of the ACP discussion. A lack of consensus was observed on the issue of after HF diagnosis for right timing of the ACP discussion across rounds (CVRs from -0.80 to -0.83); consensus was reached on the expectation of a terminal state (CVRs from 0.60 to 0.78). Content validity ratios were moderately high for Korean advance directive, ranging from 0.59 to 0.91. Experts also reached consensus about each of 5 steps of a communication model-patients' determination of decisional capacity (CVR, 0.72-1.0), awareness (CVR, 0.95-1.0), willingness for advance care planning (CVR, 0.76-0.84), family dynamics (CVR, 0.92-1.0) and patient readiness for advance care planning (CVR, 0.76-0.95).


Conclusions: A context-oriented communication model could be used to facilitate the decision-making process for palliative care and continuity of care in HF.