Primary Care Team

The Research:

The Primary Care team focused on using patient and health care professional tools to increase the uptake,impact, and access to advance care planning (ACP) for frail elderly Canadians. The team evaluated a care pathway in Alberta and BC family practices, supported by training and education, a clinician conversation guide, and patient-facing tools designed to increase the feasibility and quality of ACP conversations in primary care.

Key findings:

  • Following SIC Training and introduction to tools, clinicians described improved confidence to integrate ACP into practice.
  • The stepped care pathway is well-suited to a multidisciplinary approach to ACP:
    • The role of the physician was vital in identifying and screening patients, reviewing documentation, and
      finalizing patient values and wishes.
    • The role of clinic and support staff, who recruited patients into the care pathway and provided
      education and support, was also critical to the success of the pathway.
  • Clear, standardized documentation was critical for communication between clinicians about the care
    pathway but also to capture values and goals in the patient medical chart.
  • Clinicians cited the early involvement of the substitute decision maker (SDM) in the ACP process as
  • Physicians reported that conversations were more streamlined because patients were better prepared to
    discuss goals and wishes. Documentation was facilitated with interprofessional cooperation and role clarity.
  • The majority of patients reported feeling more heard and understood by their physician after the


1. Provide ACP/Serious Illness Conversation education and training for family physicians and allied health professionals
2. Integrate a stepped care pathway with ACP tools into routine primary care practice
3. Conduct more research about how to evaluate the above to ensure sustainability in practice
4. Conduct more research about the role of the SDM and SDM-specific ACP tools
5. Consider clinician recommendations for future research on this topic: care pathway ‘lite’ for some
patients or practices; the potential for virtual ACP in the context of COVID-19; the role of allied health; the importance of serious illness conversation training and ACP tool use.


Howard M, Elston D, De Vries B, Kaasalainen S, Gutman G, Swinton M, Carter R, Sussman T, Barwich D, Urquhart R, Jayaraman D, Munene P, You J. (2020). Implementing Advance Care Planning Tools in Practice: A Modified World Café to Elicit Barriers and Recommendations from Potential Adopters. Accepted for publication by Healthcare Quarterly, Dec 2020.

Bernard C, Tan A, Slaven M, Elston D, Heyland DK, Howard M. Exploring patient-reported barriers to advance care planning in family practice BMC Fam Pract. 2020 May 25;21(1): 94. doi: 10.1186/s12875-020-01167-0. PMID: 32450812; PMCID:PMC7249389.

Howard M, Bernard C, Klein D, Tan A, Slaven M, Barwich D, You JJ, Asselin G, Simon J, Heyland DK. Older patient engagement in advance care planning in Canadian primary care practices. Results of a multisite survey. Can Fam Physician. 2018 May; 64(5):371-377. PMID:

Principal Investigators:

Michelle Howard, PhD, MSc

Photo of Michelle HowardMcMaster University

Dr. Michelle Howard is an Assistant Professor in the Department of Family Medicine and an Associate Member of the Department of Clinical Epidemiology and Biostatics at McMaster University. Dr. Howard completed her doctorate at McMaster, and her MSc at the University of Toronto. Her research interests include evaluating and improving primary care models and understanding the mechanisms and impacts of interprofessional care in primary care practices.

Doris Barwich, MD, CCFP

photo of DorisBC Centre for Palliative Care

Doris Barwich is a Clinical Assistant Professor in the University of British Columbia Faculty of Medicine, and the Executive Director of the BC Centre for Palliative Care (BCCPC), a provincial hub to support excellence in evidence-informed practice, education, innovation, collaboration and policy development to improve care for those living with serious illness and their families. Dr. Barwich completed her MD/LMCC and Family Medicine Residency at the University of Manitoba and a Fellowship in Palliative Medicine at the University of Ottawa. Her research interests include the integration of palliative and primary care, bowel care in the palliative population, and Advance Care Planning.

Amy Tan, MD, MSc, CCFP(PC), FCFP

Photo of Amy TanUniversity of Calgary

Amy Tan is an Associate Professor and academic family physician and hospice physician in the Department of Family Medicine at the Cumming School of Medicine, University of Calgary who is on a mission to empower members of the public, patients, families, medical learners, family physicians, physicians of other disciplines, and interdisciplinary team members to engage in quality advance care planning conversations to better achieve care that meets the individual’s goals through research, education and advocacy work. She completed a Master of Science in Palliative Medicine degree from Cardiff University in the UK after completing a thesis study on family physicians’ experiences with end-of-life decision-making with surrogates of dying patients. Her research interests focus on empowering quality advance care planning in family medicine, supporting community-based primary palliative care, and effective teaching of shared decision-making with patients and families for medical learners at all stages of training.


Robin Urquhart, PhD

Photo of Robin UrquhartDalhousie University

Dr. Robin Urquhart is an Assistant Professor, in the Department of Surgery, with a cross-appointment in Community Health & Epidemiology, both at Dalhousie University. She is also an Affiliate Scientist with the QEII Health Sciences Centre, and a Senior Scientist at Beatrice Hunter Cancer Research Institute. She received her Interdisciplinary PhD in 2013 at Dalhousie University with a focus on how multi-level factors influence the movement of complex innovations into practice. Dr. Urquhart’s primary research interests relate to understanding and optimizing the movement of evidence-based innovations into clinical practice as well as the interface between evidence-based medicine and policy.


Dr. Douglas Klein, MD, MSc, CCFP
Dr. Marissa Slaven, MD
Dr. Carrie Bernard, MD

Research Staff

Ms. Dawn Elston, Research Coordinator, MA
Ms. Neha Arora, Research Coordinator, MSc
Dr. Rachel Carter, Research Manager, PhD
Ms. Diana Cochrane, Research Assistant
Mr. Abe Hafid, Research Assistant
Ms. Carley Paterson, Research Assistant, BA