Conversations Worth Having: The Perceived Relevance of Advance Care Planning among Teachers, Hospice Staff, and Pastors in Knysna, South Africa

Background: Little is known about the relevance of advance care planning (ACP), including the use of advance directives (AD) and health care power of attorney in transitional countries where access to health care is often limited. Objective: The study's objective was to determine the perceived relevance of ACP amongst select groups in the South African community, and to refine an existing tool for initiating conversations on the topic. Design: Five focus groups were recruited, with a total of 51 participants, including pastors, hospice staff, teachers, and community caregivers. Methods: The concept of ACP was introduced. Participants reflected on its relevance, how best to approach the topic, and what aspects ACP should cover. Participants also evaluated an existing tool for initiating conversations about ACP, with their respective communities in mind. Results: There was broad recognition of the unexplored benefit of ACP, as well as barriers to initiating conversations. Respondents agreed that ACP should take place before a health crisis; individual, cultural, and contextual factors were identified as factors influencing who should initiate conversations, and what to discuss. Specific factors included involving family decision makers in ACP and preferences for place of death and place of care. There was a strong wish for choices to be acted on, and participants felt advocacy was needed to improve public knowledge of the role of ACP and ADs. Conclusion: ACP is deemed relevant and helpful in this South African context. Factors for consideration include sensitivity to diverse cultural and individual preferences, available resources to meet preferences, wider participation in discussion among collectivist-oriented societies, and the role of gender in family decision making.