Understanding the Facilitators and Barriers to Serious Illness Conversations With Older Adults: A Qualitative Analysis using the Socio-Ecological Framework.

Serious illnesses impact a large and growing number of older adults globally and in Singapore. Serious illness conversations (SICs) are a useful tool for clinicians to understand patients' priorities and increase alignment between priorities and care. This study aimed to understand barriers and facilitators to SICs among older adults, noting that this population is understudied yet more impacted by serious illness. In-depth interviews were conducted with older adults living with serious illnesses (n = 11) and family caregivers (n = 6). Facilitators and barriers were identified at the individual, interpersonal, institutional, and socio-cultural levels of the socio-ecological framework. Facilitators included acceptance and awareness of their condition, patient readiness and willingness, hope and support on the journey, early and careful initiation, direct communication, accessible patient-centered and high-quality care, and religious support. Barriers included limited awareness and acceptance of their condition, poor emotional well-being, uncertainty about the future, lack of provider communication, information imbalances, low support on the journey, unclear and confusing language, inaccessible and low-quality care, religious beliefs, and cultural stigmas around prognosis and decision-making. Understanding these facilitators and barriers can inform changes in policy and clinical practice to improve SICs with older adults.