Advance care planning in the end-of-life phase: coordinating between social worlds.

Advance care planning (ACP) for people in the last phase of life, living at home with complex care needs, is increasingly seen as a valuable practice to deliver patient-centred care and to prevent unnecessary hospitalizations and delay nursing home admissions. A notable difficulty of ACP is the coordination of ACP-practices over various domains involved in patient care (e.g. home care, GP care, hospital care). We draw on ethnographic data on ACP practices in home care, GP-care and hospital care in the Netherlands. We use social worlds theory to analyse the different information requirements of collaborating social worlds in end-of-life care (home care; GP care; hospital care) and show how actors succeed in coordinating ACP through three different coordinating practices: (1) via articulation work; (2) via boundary objects; and (3) via patients and their loved ones as boundary subjects. Furthermore, we articulate the conditions under which written ACP-agreements emerge as boundary objects to coordinate ACP practices in different domains of patient care. In the paper, we contribute to literature on coordination of care across domains by presenting a holistic account of care coordination practices in end-of-life care.