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Implementing Advance Care Planning - A Cluster Randomised Controlled Study

Advance care planning (ACP) is a tool to comply with the ethical and legal imperative to involve both the patient and their next of kin in the planning of current and future treatment and care.

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About the project

This multicenter project is both an implementation and an intervention project. It will increase knowledge on whether implementation of ACP actually improves relevant outcomes in real-life services. 


  • Map the current level of implementation of ACP for severely ill elderly people living at home in selected hospital wards and community services.
  • Identify the most important facilitators and barriers among all relevant stakeholders - including moral dilemmas and conflicting interests - to implementing ACP on a) the clinical level and b) the organisational and policy level.
  • Develop and use an innovative and sustainable ACP implementation support program (ISP) and tailor the evaluation plan.
  • Investigate whether the ISP improves ACP implementation, and whether better implementation of ACP improves outcomes for patients, family, and services.
  • Measure the cost-effectiveness of the ACP and the implementation support.


The project has four work packages: Mapping the current level of implementation of ACP in selected hospital and community services for home-dwelling elderly patients with severe somatic diseases (WP1). Evaluation of the implementation and its effects on outcomes (WP2), barriers and facilitators for implementation for stakeholders at the clinical level, and moral dilemmas (WP3), barriers and facilitators at the organizational and policy level, and cost-effectiveness (WP4)


The Research Council of Norway

Start - Finish

October 2020 – October 2025


Published Sep. 14, 2020 9:36 AM - Last modified Feb. 16, 2022 10:31 AM



Detailed list of participants