Trauma-Informed Care, Advance Care Planning and grief – integrating approaches to enhance care

Trauma-Informed Care, Advance Care Planning and grief – integrating approaches to enhance care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Trauma-Informed Care, Advance Care Planning and grief – integrating approaches to enhance care Brendan Myhill, Michael Dash, Ghauri Aggarwal, Anthoulla Mohamudally, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7285816/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose - Application of a Trauma-Informed Care (TIC) approach in palliative and end-of-life care is recent and under-researched. This study aimed to describe the experience of people bereaved following a death in a Local Health District. This included exploring the relationship between ACP and bereavement and whether care provided was consistent with TIC principles. Methods – Invitations for an online survey were sent to bereaved Next of Kin of adult patients who had died in a metropolitan health district in Australia between September 2021 and November 2022. Data were analysed using descriptive statistics and a Z test. Results – Response rate was 15.7% (n=293). Of participants involved in ACP discussions, 38% reported a positive impact on their post-death grief. Analysis against all variables showed the strongest association for positive impacts of ACP on grief where discussions were held in line with principles of TIC. Associations were also shown between care provision in line with TIC and family being involved in decisions at the level they wanted to be, in the last 3 months of life. Conclusion - A trauma-informed approach to ACP has significant positive impacts on family being involved in decisions at the level they wanted to be, and on their later grief. These results contribute a new perspective from bereaved family members reporting on the impact ACP discussions had on subsequent grief experiences, demonstrating the benefits of a Trauma-Informed approach in ACP. The principles of TIC should be used to underpin ACP practice, and education for healthcare professionals on ACP. trauma informed care advance care planning grief bereavement end-of life-care Figures Figure 1 Figure 2 Introduction Grief is a natural response to loss of any type. Bereavement is a multifaceted experience specifically related to the death of a significant person, and includes emotional, physical, social, cognitive and psychological aspects[ 23 , 33 ]. Studies have shown that healthcare workers (HCWs) can contribute to more positive experiences for bereaved people following an expected death through effective end-of-life (EOL) communication, providing emotional, psychological and practical support[ 8 , 17 , 19 , 38 ] and providing care which is compassionate, competent[ 19 ] and holistic[ 8 ]. Advance Care Planning (ACP) can also influence bereavement. ACP is “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care” with a goal to “help ensure that people receive medical care that is consistent with their values, goals and preferences”[ 34 ]. Limited studies have explored ACP related bereavement outcomes, a small number have shown no benefit or no significant effect[ 15 , 22 , 36 ]. However a greater number of studies show benefits in caregiver outcomes following a death such as lower stress and depression[ 6 ], lower anxiety, stress and posttraumatic distress[ 31 , 32 ] and decreased grief scores[ 9 ]. There is increasing interest in Trauma-Informed Care (TIC) in EOL and palliative care[ 4 , 5 , 21 , 25 ]. The Substance Abuse and Mental Health Services Association defines trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being”[ 27 ]. Studies report that 50–70% of people have had exposure to at least one psychological trauma in their lifetime[ 10 , 11 ]. Trauma is likely to be present at even higher rates for patients at EOL and in palliative care, as they tend to be older with more likelihood of previous trauma exposure, have a higher probability having experienced intensive medical interventions which can be traumatic and may also experience trauma due to the threat to their life from illness[ 11 ]. Family members and carers of patients who die in healthcare settings may also be exposed to trauma[ 28 , 35 ]. This is well documented in the intensive care setting[ 12 , 14 , 16 , 35 ] and also observed following an expected death in palliative care[ 28 ]. Patients with a history of traumatic life events can become distressed or re-traumatized as the result of healthcare experiences. These patients and their families can benefit from a trauma-informed approach that is sensitive to their unique needs[ 24 ]. A trauma-informed service recognises the signs, symptoms and impacts of trauma and responds by implementing policies, education and ways of working which seek to avoid causing trauma or re-traumatization[ 27 ]. This is guided by the principles of safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, and consideration of cultural, historical and gender issues[ 27 ]. Given the high prevalence of trauma in our society it is recommended that TIC is employed with all patients as a universal precautions approach 22 . Research into trauma in palliative and EOL care settings is limited, as is guidance about implementation of a trauma-informed approach. Where it exists this often focusses on veteran populations or specific contexts such as during the COVID-19 pandemic[ 25 ] , 20 . As such, while some education resources exist 21 there is a lack of an agreed framework of what trauma-informed practice should look like in palliative and EOL care, or ACP. A recent case report may be of assistance here, with demonstration of the practical application of the principle of TIC, with strategies such as fostering trust and honest relationships, flexible approaches to care, ways to address power imbalances and a safety netting approach 43 . More research is required to support recent calls for implementation of a trauma-informed approach in palliative and EOL care[ 5 ]. Further research is also required into family and carer experiences of ACP and the factors within this which may shape their experiences of grief and bereavement. Thus, the aim of our study was to describe the experience of people bereaved following a death in one Local Health District (LHD) as well as exploring the impact of healthcare interactions on bereavement experiences. Secondary objectives included exploring the relationship between ACP and bereavement experiences and exploring whether care prior to and following a death was provided in a way that is consistent with a trauma-informed approach. Methods Study Setting This study was conducted in (removed to anonymise), a metropolitan health district, comprising 3 acute care hospitals, a specialist palliative care unit, a sub-acute hospital and care at home through community health services. The study included families of patients who had died between September 2021 and November 2022. This research study was approved by the (removed to anonymise) (reference 2022/ETH01743). Development of the survey As no validated survey tool could be found that aligned fully with the aims of this study a customised survey tool was developed, drawing on the validated CaregiverVoice survey[ 30 ]. Modifications were made to reflect the language used in the Australian healthcare system, and additional questions to meet study objectives. Within the survey, participants are given a definition of Advance Care Planning as “planning for care in case your family member/friend is not able to make decisions for themselves in the future”, a definition drawn from the CaregiverVoice survey. The survey was tested by the investigator team including a consumer co-investigator, with additional review by consumers. A copy of the survey is available as a supplementary file. Participants and recruitment Inclusion criteria for the study were that the participant was the listed main contact person for a patient aged over 18 years who had died in the preceding 2–15 months in the health district. Participants were also required to be 18 years or older and able to communicate in English. Exclusions were due to incomplete or overseas contact details for the potential participant, or if the deceased patient had only had contact with an outpatient clinic, or place of death was not clearly recorded. An invitation to participate in the anonymous online survey was sent by mail to participants who met the inclusion criteria. For each deceased person one survey was sent to a family member, the person listed as the main contact Participants unable to take part in the online survey were invited to document their responses by phone. Two bereaved participants reported requiring an interpreter for healthcare discussions but were able to undertake the survey requirements themselves. Statistical Methods Descriptive statistics for primary and secondary outcomes were presented for the total sample and for comparison groups formed based on patient characteristics and key participant responses. Independent Z-Test tests were used to test the significance of the differences between percentages for selected columns, a test between independent proportions. Statistical significance was declared when computed p-values were < 0.05. Continuous data are reported using mean and standard deviation and categorical data are reported using frequencies and percentages. In the analysis each question was run against every other question in a univariate analysis. This paper reports associations which were statistically and clinically significant by the investigator team. All statistical analysis was performed using Wincross V15 (The Analytical group, Scottsdale, AZ 85260). Results For this study, 293 survey responses were received, with a response rate of 15.7%. This article reports the results from this study which relate to TIC, ACP and their relationship to grief. Figure 1 shows a flowchart of participation and Table 1 displays demographic information. Table 2 outlines the survey results which give context to the circumstances of deaths, involvement in ACP, and bereaved participants reports of their own involvement in decision making in the last 3 months of life. Insert Table 1 Insert Table 2 Figure 2 displays the ratings that bereaved participants gave when asked to consider their contact with healthcare workers in the months prior to the death in relation to the principles of TIC. These results show high levels of bereaved participants reporting that they felt safe, that they could trust HCW, that staff collaborated with them, gave them choices and listened to them. There were associations between reports of care provision in line with the principles of TIC, and family members being involved in decisions at the level they wanted to be in the last 3 months of life. Of those participants who reported involvement in decisions at the level they wanted to be, 40.5% strongly agreed that in months prior to the death that they felt staff listened, 41.7% strongly agreed that staff gave choices where possible, 41.6% strongly agreed that staff collaborated about care and plans, 45.7% strongly agreed that they felt they could trust HCW, and 57.4% strongly agreed that they felt safe when interacting with HCW. These results reached statistical significance (p<0.05). While large proportions of respondents also agreed that care in the months prior to the death was in line with TIC principles, this was only statistically significant (p<0.05) for feeling safe when interacting with HCWs (33.3%), feeling they could trust HCWs (41.4%),%) that HCWs collaborated with them (39.1%) and that HCW listened to them (39.3%). Figure 2 also shows the ratings bereaved participants gave when reflecting on their experience of ACP discussions in relation to the principles of TIC. These results indicated even stronger levels of alignment with TIC principles. There were strong associations (p<0.05) between reports of ACP discussions being held in line with the principles of TIC, and bereaved family members being involved in decisions at the level they wanted to in the last 3 months of life. Of those bereaved family members who agreed that they were involved in decisions as much as they wanted to be, 51.7% strongly agreed that staff listened to them during discussions about Advance Care Planning, 44.0% strongly agreed that staff gave choices about how the discussions were held, and 49.6% reported that staff held the ACP discussion in a collaborative manner. Table 3 displays results relating to participants reporting their perception of the impact of ACP discussions on their grief. Participants who had been involved in ACP discussions (n=138) were asked if they felt the discussion had impacted on their grief. 38.4% reported that ACP discussions had impacted their grief positively, 8.7% a negative impact, 30.4% no impact and 22.5% were not sure. Insert Table 3 When examining variables which could influence the impact ACP discussions had on later experiences of grief, care in line with a trauma-informed approach was found to have the strongest association with ACP impacting positively on grief. The strongest predictors of whether a bereaved person felt that ACP discussions had a positive impact on their grief was where they strongly agreed that ACP discussions were held by staff in a collaborative way (this group had increased reports of positive impact to 49.2%), or strongly agreed that staff gave them choices in how the discussion was held (this group had increased reports of positive impact to 50%), or where they strongly agreed that staff listened (this had group increased reports of positive impact to 50.8%). TIC was the strongest association as compared with the other variables such as the diagnosis of the deceased or which healthcare provider led the ACP discussions. Discussion Our results show a strong association between care being provided in line with the principles of TIC and family members being involved in decisions at the level they wanted to be in the last 3 months of life. Given that many people within the general population have been exposed to trauma during their lifetime[10, 11] and high levels of trauma exposure for those in healthcare settings[11, 28, 35] the reasoning underpinning a trauma-informed approach to the care in the last months of life is clear. The results of our study particularly highlight the positive impacts that ACP can have on bereavement experiences. 38.4 % of participants involved in ACP reported the discussions had a positive impact on their grief. These results significantly improved if participants reported that ACP discussions were held in line with TIC principles, especially for those who strongly agreed the discussion was collaborative, that they were given choices, and were listened to. Findings contribute to a new, self-reported perspective from bereaved family members on the connection between their participation in ACP discussions and subsequent impact on their grief. This resonates with the work of previous studies that report ACP possesses benefits for caregivers in bereavement, such as lower stress, depression, anxiety and posttraumatic distress, and decreased grief scores[6, 9, 31, 32]. Given that participants may have interpreted ACP to included broader planning discussions, these positive results indicate likely beneficial impacts on grief from drawing on a trauma informed approach for any discussions regarding serious illness and planning. Our study contributes to the existing literature demonstrating the ways in which ACP can promote healthy bereavement experiences. Previous studies posit that ACP assists with grief and bereavement by increasing family knowledge and understanding of patients’ wishes with possible subsequent reduced distress in bereavement[6, 31], along with reducing decision burden and improved satisfaction with the quality of death[6]. Falzarano and colleagues consider that completion of an Advance Care Directive (ACD) may help with terminal illness acknowledgement for patients and families, increasing carer’s mental preparation for the death, perhaps encouraging improved bereavement outcomes[9]. This preparedness includes the domains of information, emotional preparation and pragmatic preparation[3]. ACP discussions can assist with information-based preparation through education about the illness and its expected progression. These discussions can subsequently equip families for the emotional adjustment over time, attending to relational aspects of death preparation and prompting important conversations and pragmatic preparations such as legal, financial and funeral planning[8]. A trauma-informed approach to ACP enhances potential positive impacts in bereavement. Waldrop and McGinley note however that communication gaps can be left if a check box approach to documents is relied on for EOL preparation for caregivers[37]. They advocate ACP discussions which consider the whole-of-life context of a person and their family, their goals and their values. These create opportunities for open discussions with family, exploring distress and discomfort, teaching and preparing in order to promote understanding of their situation and facilitate coping[18]. A systematic review of evidence on ACP tools also notes a shift from a focus on preferences for specific treatments to a greater emphasis on values-based discussions[20]. These holistic approaches to ACP and EOL conversations can be an important part of death preparedness for caregivers[8]. A trauma-informed approach to ACP can create a space where these holistic discussions feel safe and possible and can assist clinicians in how and when to hold these conversations. Our results show the positive impacts that this trauma-informed approach to ACP discussions can have on later grief. The approaches of ACP and TIC are complementary. A recent review of the evidence on ACP outlines the core elements of ACP as including: Maximizing the person’s ability to engage; Exploring their readiness to engage and individualising the process; Exploring the person’s understanding of their situation; Exploring patient health related experiences, personal values, concerns and their personal goals; Providing education; Clarifying goals and checking whether these are realistic; Discussing involving a personal representative and their level of involvement; and, explaining that goals and preferences can change (emphasising ACP as a process)[26]. This approach works well when underpinned by trauma-informed care principles which focus on safety in the environment and psychological safety in the discussion, trustworthiness and transparency, collaboration and mutuality, and an empowering approach to discussions that promotes choice and truly fosters the voice and input of consumers and families[4, 27]. Our findings show the benefit of using a trauma-informed approach in ACP. Table 4 provides a proposed framework translating these ideas from abstract concepts into practice. While TIC aligns with the principles of palliative care, patient centred care and ACP, the smaller but significant minority of respondents who reported that their ACP discussions did not fit with TIC principles points to a need to a universal approach and education to support this. A trauma-informed approach can enhance the provision of patient centred care. We advocate for this proposed framework to be incorporated into ACP education. The framework draws on the practical trauma-informed models of Dhawan and LeBlanc for shared decision making with racial minorities in a hematologic setting, and Brown and colleagues work on trauma-informed palliative medicine[4, 7], synthesising and applying these principles in relation to ACP. The framework aims to level the power differences that exist in healthcare due to the specialist knowledge of HCWs[29] which is especially important for those who may have experienced exploitation of power through interpersonal violence[1]. Consideration has been given to maximising choice for patients and families, as our results show that reports of being offered choices about ACP discussions were lower than for the other TIC domains. This perceived lack of choice may be due to restrictions on choices that can be offered, for example when offering resuscitation isn’t a medically appropriate option, or when circumstances restrict choice about timing. Insert Table 4 Implications for practice and future research: This study illustrates potential benefits of using a trauma-informed approach in ACP. The concepts of TIC should underpin ACP practice as shown in our proposed framework, which can be used in education for HCWs on ACP processes and communication, and could be used to guide all serious illness conversations Further research is required into the practical applications of a trauma-informed approach in ACP, EOL and palliative care. The associations found in our results could be further investigated through qualitative and quantitative research. Attention is required in future research to the experiences of patients and families of Trauma-informed Care in these settings, especially for those who have had past experiences of trauma. Strengths and limitations The strengths of this study include a focus on lived experience, including contributions of consumer co-investigator C.T, as well as the project’s development and analysis being informed by a multidisciplinary approach. Limitations of our study include a lack of specific inclusion of Culturally and Linguistically Diverse and Aboriginal and Torres Strait islander voices in the development of the study, and in respondents. Future research could include translation of materials to be more inclusive. Responses may also have been impacted by memory or recall bias given that some respondents were completing the survey over a year past the time of death. The generalisability of our data could have been increased by the inclusion of other institutions, given our sample is from one LHD, and a higher response rate. It is known, however, that survey response rates for sensitive surveys such as those in bereavement tend to be lower than with other populations[2, 13]. This lower response rate meant that some categories had only a small number of respondents which reduced our ability to determine if there was a significant association for some questions, however any results that were reported as significant had sufficient numbers for statistical analyses. A lower response rate increases the possibility that there may be bias in the sample, as such it would be ideal to repeat this survey in other settings with a broader sample. The time period of our survey also included periods impacted by COVID-19 and visiting restrictions in health services which impacted care systems and access to support. Despite the challenges of this period, most participants still reported experiences of care in line with TIC principles. Conclusion The results of this study show that when care is provided in line with the principles of a trauma-informed approach, family and carers are more likely to report being involved in decision making in the last months of life at a level they wanted to be. It was also demonstrated that the potential positive impacts of ACP discussions on grief after death increase markedly where the discussions were held in strong alignment with principles of trauma-informed care. Our proposed framework shows how these TIC principles can be used in practice in ACP. Findings can inform education for healthcare workers on trauma-informed approaches in palliative and end of life care, and ACP interventions. Further research is required into the practical application of trauma-informed approaches in these areas. Declarations Funding This work was supported by funding received from Sydney LHD (no grant number). This support is gratefully acknowledged. The funder had no direct role in the design of the study; analyses or interpretation of data; writing of the manuscript; or the decision to publish the results. Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Concord Repatriation General Hospital Human Research Ethics Committee (reference 2022/ETH01743). Consent to participate Informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable Availability of data The datasets used and/or analysed during this study are available from the corresponding author on reasonable request. Competing interests The authors declare they have no relevant financial or non-financial interests, or relevant disclosures. 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Improving maternity care with survivors of childhood sexual abuse J Nurse Midwifery 43: 287-295 Seow H, Bainbridge D, Brouwers M, Pond G, Cairney J (2017) Validation of a modified VOICES survey to measure end-of-life care quality: the CaregiverVoice survey BMC Palliat Care 16: 44 Song MK, Ward SE, Fine JP, Hanson LC, Lin FC, Hladik GA, Hamilton JB, Bridgman JC (2015) Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates Am J Kidney Dis 66: 813-822 Song MK, Ward SE, Lin FC, Hamilton JB, Hanson LC, Hladik GA, Fine JP (2016) Racial Differences in Outcomes of an Advance Care Planning Intervention for Dialysis Patients and Their Surrogates J Palliat Med 19: 134-142 Stroebe M, Schut H, Stroebe W (2007) Health outcomes of bereavement Lancet 370: 1960-1973 Sudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK (2017) Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel J Pain Symptom Manage 53: 821-832 e821 Tang ST, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC (2021) Course and predictors of posttraumatic stress-related symptoms among family members of deceased ICU patients during the first year of bereavement Crit Care 25: 282 Vandenbogaerde I, De Vleminck A, Cohen J, Verkissen MN, Lapeire L, Ingravallo F, Payne S, Wilcock A, Seymour J, Kars M, Gronvold M, Lunder U, Rietjens J, van der Heide A, Deliens L (2022) Advance care planning-family carer psychological distress and involvement in decision making: the ACTION trial BMJ Support Palliat Care Waldrop DP, McGinley JM (2022) Beyond Advance Directives: Addressing Communication Gaps and Caregiving Challenges at Life's End J Pain Symptom Manage 63: 415-422 Wen FH, Chou WC, Hou MM, Su PJ, Shen WC, Chen JS, Chang WC, Hsu MH, Tang ST (2022) Associations of death-preparedness states with bereavement outcomes for family caregivers of terminally ill cancer patients Psychooncology 31: 450-459 Tables Table 1 – Demographics Variable Deceased Bereaved (participant) Gender (n= 245) (n = 246) Male 136 (55.5%) Male 55 (22.4%) Female 109 (44.5%) Female 190 (77.2%) Non-Binary 0 Non-Binary 1 (0.4%) They used a different term 0 They used a different term 0 Prefer not to answer 0 Prefer not to answer 0 Age (n=245) (n = 246) 18-29 4 (1.6%) 18-29 3 (1.2%) 30-39 3 (1.2%) 30-39 8 (3.3%) 40-49 11 (4.5%) 40-49 27 (11%) 50-59 10 (4.1%) 50-59 71 (28.9%) 60-69 30 (12.2%) 60-69 73 (29.7%) 70- 79 72 (29.4%) 70- 79 52 (21.1%) 80-89 58 (23.7%) 80-89 9 (3.7%) 90+ 57 (23.3%) 90+ 3 (1.2%) Sexual orientation (n = 243) (n = 242) Straight (Heterosexual) 228 (93.8%) Straight (Heterosexual) 222 (91.7%) Gay or Lesbian 7 (2.9%) Gay or Lesbian 13 (5.4%) Bisexual 1 (0.4%) Bisexual 2 (0.8%) They used a different term 1 (0.4%) I use a different term 0 Don’t know 3 (1.2%) Don’t know 0 Prefer not to answer 3 (1.2%) Prefer not to answer 5 (2.1%) Place of birth (n = 245) (n = 246) Australia 126 (51.4%) Australia 180 (73.2%) Italy 22 (9%) United Kingdom 14 (5.7%) United Kingdom 21 (8.6%) China 7 (2.8%) Greece 15 (6.1%) New Zealand 6 (2.4%) China 11 (4.5%) Greece 5 (2%) India 4 (1.6%) Italy 5 (2%) Other 46 (18.8%) Other 29 (11.8%) Main language at home (n = 245) (n = 246) English 183 (74.7%) English 227 (92.3%) Italian 16 (6.5%) Cantonese 5 (2%) Greek 14 (5.7%) Mandarin 4 (1.6%) Cantonese 7 (2.9%) Greek 3 (1.2%) Mandarin 5 (2%) Italian 2 (0.8%) Spanish 5 (2%) Spanish 2 (0.8%) Other 15 (6.2%) Other 3 (1.2%) Interpreter requirement (n = 234) (n =244) Yes 31 (13.2%) Yes 2 (0.8%) No 203 (86.8%) No 242 (99.2%) Time since death (n = 244) Less than 2 months 2 (0.8%) 2-4 months 41 (16.8%) 4-6 months 42 (17.2%) 6 months - 1 year 93 (38.1%) Longer than 1 year 66 (27.0%) Main illness (deceased) (n =246) Cancer 113 (45.9%) Heart Disease 26 (10.6%) They were not ill – died suddenly 14 (5.7%) Lung disease 13 (5.3%) Kidney or Liver Disease 11 (4.5%) COVID-19 9 (3.7%) Influenza or Pneumonia 9 (3.7%) Stroke 9 (3.7%) Neurological disease 8 (3.3%) Other 34 (13.8%) Relationship to deceased (n = 246) Son/Daughter – 112 (45.5%) Spouse (married or De Facto) 97 (39.4%) Parent/Parent-in-law 15 (6.1%) Brother/sister 7 (2.8%) Friend 7 (2.8%) Son-in-law/daughter-in-law 2 (0.8%) Other 6 (2.4%) Table 2 - Circumstances of death, ACP & involvement in decision making Did they know they were likely to die? (n = 246) Yes, certainly 101 (41.1%) Yes, probably 62 (25.2%) Probably not 27 (11%) No, definitely not 36 (14.6%) Not sure 20 (8.1%) How long had they been ill before they died? (n = 242) They were not ill – they died suddenly 9 (3.7%) Less than 24 hours 7 (2.9%) One day or more but less than a week 13 (5.4%) One week or more but less than a month 33 (13.6%) One month or more but less than six months 50 (20.7%) Six months or more but less than a year 32 (13.2%) One year or more 98 (40.5%) Where did they die? (n = 246) Home 52 (21.1%) Hospital ward 97 (39.4%) Intensive Care Unit or Emergency Department 36 (14.6%) Palliative Care Unit 57 (23.2%) Other 4 (1.6%) Was the person given the opportunity to discuss ACP with their health providers? (n = 244) Yes, definitely 82 (33.6%) Yes, to some extent 57 (23.4%) No, they were not given the opportunity 73 (29.9%) Don’t know 32 (13.1%) Who was the main healthcare provider who discussed ACP with them? (n = 138) Palliative Care Doctor 40 (29%) General Practitioner 28 (20.3%) Specialist Palliative Care Nurse 21 (15.2%) Other doctor/specialist (e.g. cardiologist) 14 (10.1%) Oncologist 10 (7.2%) Community Nurse 6 (4.3%) Hospital Nurse 5 (3.6%) Geriatrician 5 (3.6%) Don’t know 6 (4.3%) Other 3 (2.2%) Looking back over the last three months of their life were you involved in decisions as much as you wanted to be? (n = 244) I was involved as much as I wanted to be 175 (71.7%) I would have liked to be more involved 46 (18.9%) I would like to have to less involved 1 (0.4%) Don’t know 2 (0.8%) N/A, they were not ill – they died suddenly 20 (8.2%) Table 3. Bereaved participants reports of ACP discussion impact on their grief since the death Report on impact of ACP discussions on grief since death Positive Negative No impact Not sure Overall results of ACP discussions (n=138) 53 (38.4%) 12 (8.7%) 42 (38.4%) 31 (22.5%) Main provider who discussed ACP: Palliative care doctor (n=40) 19 (47.5%) 2 (5%) 12 (30%) 7 (17.5%) General practitioner/primary care physician (n=27) 12 (44.4%) 1 (3.7%) 10 (37%) 4 (14.8%) Specialist palliative care nurse (n=21) 6 (28.6%) 3 (14.3%) 7 (33.3%) 5 (23.8%) Oncologist (n=10) 3 (30%) 2 (20%) 2 (20%) 3 (30%) Geriatrician (n=5) - 1 (20%) 3 (60%) 1 (20%) Other doctor/specialist (e.g. cardiologist) (n=14) 5 (35.7%) 1 (7.1%) 3 (21.4%) 5 (35.7%) Community nurse (n=6) 3 (50%) 1 (16.7%) 1 (16.7%) 1 (16.7%) Hospital nurse (n=5) 2 (40%) - 2 (40%) 1 (20%) Other (n=3) - 1 (33.3%) 1 (33.3%) 1 (33.3%) Don’t know (n=6) 2 (33.3%) - 1 (16.7%) 3 (50%) Main illness of the deceased Cancer (n=82) 38 (46.3%) 6 (7.3%) 23 (28%) 15 (18.3%) Non-cancer (n=56) 15 (26.8%) 6 (10.7%) 19 (33.9%) 16 (28.6%) Reports of TIC principles during ACP discussions I felt safe Strongly Agree (n=79) 37 (46.8%) 3 (3.8%) 26 (32.9%) 13 (16.5%) Agree (n=41) 15 (36.6) 5 (12.2%) 12 (29.3%) 9 (22%) Neutral (n=14) - 3 (21.4%) 3 (21.4%) 8 (57.1%) Disagree (n=0) - - - - Strongly disagree (n=2) - 1 (50%) 1 (50%) - I felt I could trust the healthcare workers Strongly Agree (n=67) 30 (44.8%) 3 (4.5%) 23 (34.3%) 11 (16.4%) Agree (n=53) 22 (41.5%) 2 (3.8%) 15 (28.3%) 14 (26.4%) Neutral (n=10) - 4 (40%) 3 (30%) 3 (30%) Disagree (n=1) - - - 1 (100%) Strongly disagree (n=5) - 3 (60%) 1 (20%) 1 (20%) Staff held the discussion in a collaborative way Strongly Agree (n=63) 31 (49.2% 1 (1.6%) 21 (33.3%) 10 (15.9%) Agree (n=54) 19 (35.2%) 4 (7.4%) 16 (29.6%) 15 (27.8%) Neutral (n=16) 2 (12.5%) 5 (31.3%) 3 (18.8%) 6 (37.5%) Disagree (n=1) - - 1 (100%) - Strongly disagree (n=3) - 2 (66.7%) 1 (33.3%) - Staff gave choices about how the discussion was held Strongly Agree (n=54) 27 (50%) 1 (1.9%) 17 (31.5%) 9 (16.7%) Agree (n=48) 20 (41.7%) 1 (2.1%) 15 (31.3%) 12 (25%) Neutral (n=25) 4 (16%) 4 (16%) 8 (32%) 9 (36%) Disagree (n=6) - 5 (83.3%) 1 (16.7%) - Strongly disagree (n=2) - 1 (50%) 1 (50%) - I felt staff listened to me Strongly Agree (n=65) 33 (50.8%) 1 (1.5%) 22 (33.8%) 9 (13.8%) Agree (n=50) 17 (34%) 4 (8%) 15 (30%) 14 (28%) Neutral (n=17) 2 (11.8%) 5 (29.4%) 3 (17.6%) 7 (41.2%) Disagree (n=1) - - 1 (100%) - Strongly disagree (n=3) - 2 (66.7%) 1 (33.3%) - Table 4 – A framework for a trauma-informed approach to Advance Care Planning discussions. Key Principles for TIC interventions (SAHMSA 2014 and Brown 2020) Clinician actions in ACP practice (Brown 2020, Dhawan 2021) Safety: Promote physical safety in the environment and psychological safety in relationships Communicate the intention to discuss Advance Care Planning (aim to flag this prior to the discussion). Communicate what to expect during the discussions. Clarify patient preferences about who they would like to be present during particular discussions. Be aware of nonverbal cues for anxiety or distress and respond (explore concerns, provide support and reassurance, adapt as required, pause discussion if needed and return at a later date). Hold discussion in an appropriate environment allowing the option for planned discussions in privacy where possible. Allocate appropriate time so that the conversation in not rushed Trustworthiness & Transparency: Provide consistent information and build rapport Provide honest information about the illness and care options in accordance with individual preferences as expectations and preferences may vary. This may include the rate and quantity of information. Continual rapport building (emphasising ACP as a process) Acknowledge the uncertainty of illness and reassure of ongoing support and care. Peer Support: Increase recovery and healing by sharing of stories and lived experiences Promote connection with others e.g. asking “Who else might you talk to about your preferences/wishes/this conversation?” Provide peer support options if indicated Collaboration and Mutuality : Promote sense of control by partnering and levelling power differences Respect that patients can have all the facts (if they want them) and are able to make decisions. Elicit and address patient concerns With consent encourage involvement of their family/a support person in decisions and plans. Seek consent to allow discussions to occur with their family/support person to support the ongoing process Empowerment, Voice, and Choice : Foster resilience by encouraging autonomy and use of internal strengths and resources Introduce the idea of ACP early, to allow for patient to take part in the discussion when ready (if circumstances allow). Ask patients who they would like present for ACP discussions. Ask patients and families about the level of involvement they want in the process of decision making. Use language that can be easily understood. Listen to patient and family concerns and respond. Emphasise that ACP is an ongoing process, and patients can change their minds or revisit discussions. Cultural, Historical, and Gender Issues: Reduce re-traumatization and increase healing and recovery by identifying and considering intersectional identities (noting that different aspects of a person's identity may increase their risk of encountering forms of marginalisation or discrimination e.g. age, gender, sexual orientation etc.). Approach patients with curiosity rather than assumptions based on cultural/gender stereotypes. Gently explore their history and story. Understand that trauma relating to these issues are key risk factors for recurrent trauma. If a history of trauma is disclosed, offer options for support and explore with the person what their past experience might mean for them in terms of the care and support they require in future. Check in with the person afterwards to see if they require any further support. Additional Declarations No competing interests reported. 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2","display":"","copyAsset":false,"role":"figure","size":136934,"visible":true,"origin":"","legend":"\u003cp\u003eTIC ratings of participants contact with healthcare workers in the months prior to the death and of participant discussions with healthcare workers about Advance Care Planning\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7285816/v1/afc35e735810faa0e965cfe6.png"},{"id":97900587,"identity":"bd8b8769-1078-4e95-961b-6e57a6ec014b","added_by":"auto","created_at":"2025-12-10 15:45:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1418032,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7285816/v1/5b674955-9bde-4942-8660-f29c400b7859.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Trauma-Informed Care, Advance Care Planning and grief – integrating approaches to enhance care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGrief is a natural response to loss of any type. Bereavement is a multifaceted experience specifically related to the death of a significant person, and includes emotional, physical, social, cognitive and psychological aspects[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Studies have shown that healthcare workers (HCWs) can contribute to more positive experiences for bereaved people following an expected death through effective end-of-life (EOL) communication, providing emotional, psychological and practical support[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and providing care which is compassionate, competent[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and holistic[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdvance Care Planning (ACP) can also influence bereavement. ACP is “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care” with a goal to “help ensure that people receive medical care that is consistent with their values, goals and preferences”[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Limited studies have explored ACP related bereavement outcomes, a small number have shown no benefit or no significant effect[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. However a greater number of studies show benefits in caregiver outcomes following a death such as lower stress and depression[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], lower anxiety, stress and posttraumatic distress[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and decreased grief scores[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere is increasing interest in Trauma-Informed Care (TIC) in EOL and palliative care[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The Substance Abuse and Mental Health Services Association defines trauma as resulting from “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being”[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies report that 50–70% of people have had exposure to at least one psychological trauma in their lifetime[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Trauma is likely to be present at even higher rates for patients at EOL and in palliative care, as they tend to be older with more likelihood of previous trauma exposure, have a higher probability having experienced intensive medical interventions which can be traumatic and may also experience trauma due to the threat to their life from illness[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Family members and carers of patients who die in healthcare settings may also be exposed to trauma[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This is well documented in the intensive care setting[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and also observed following an expected death in palliative care[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePatients with a history of traumatic life events can become distressed or re-traumatized as the result of healthcare experiences. These patients and their families can benefit from a trauma-informed approach that is sensitive to their unique needs[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A trauma-informed service recognises the signs, symptoms and impacts of trauma and responds by implementing policies, education and ways of working which seek to avoid causing trauma or re-traumatization[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This is guided by the principles of safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice and choice, and consideration of cultural, historical and gender issues[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Given the high prevalence of trauma in our society it is recommended that TIC is employed with all patients as a universal precautions approach\u003csup\u003e22\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eResearch into trauma in palliative and EOL care settings is limited, as is guidance about implementation of a trauma-informed approach. Where it exists this often focusses on veteran populations or specific contexts such as during the COVID-19 pandemic[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003csup\u003e, 20\u003c/sup\u003e. As such, while some education resources exist\u003csup\u003e21\u003c/sup\u003e there is a lack of an agreed framework of what trauma-informed practice should look like in palliative and EOL care, or ACP. A recent case report may be of assistance here, with demonstration of the practical application of the principle of TIC, with strategies such as fostering trust and honest relationships, flexible approaches to care, ways to address power imbalances and a safety netting approach \u003csup\u003e43\u003c/sup\u003e. More research is required to support recent calls for implementation of a trauma-informed approach in palliative and EOL care[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFurther research is also required into family and carer experiences of ACP and the factors within this which may shape their experiences of grief and bereavement. Thus, the aim of our study was to describe the experience of people bereaved following a death in one Local Health District (LHD) as well as exploring the impact of healthcare interactions on bereavement experiences. Secondary objectives included exploring the relationship between ACP and bereavement experiences and exploring whether care prior to and following a death was provided in a way that is consistent with a trauma-informed approach.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was conducted in (removed to anonymise), a metropolitan health district, comprising 3 acute care hospitals, a specialist palliative care unit, a sub-acute hospital and care at home through community health services. The study included families of patients who had died between September 2021 and November 2022.\u003c/p\u003e\u003cp\u003eThis research study was approved by the (removed to anonymise) (reference 2022/ETH01743).\u003c/p\u003e\u003cp\u003e\u003cb\u003eDevelopment of the survey\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs no validated survey tool could be found that aligned fully with the aims of this study a customised survey tool was developed, drawing on the validated CaregiverVoice survey[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Modifications were made to reflect the language used in the Australian healthcare system, and additional questions to meet study objectives. Within the survey, participants are given a definition of Advance Care Planning as “planning for care in case your family member/friend is not able to make decisions for themselves in the future”, a definition drawn from the CaregiverVoice survey. The survey was tested by the investigator team including a consumer co-investigator, with additional review by consumers. A copy of the survey is available as a supplementary file.\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants and recruitment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInclusion criteria for the study were that the participant was the listed main contact person for a patient aged over 18 years who had died in the preceding 2–15 months in the health district. Participants were also required to be 18 years or older and able to communicate in English. Exclusions were due to incomplete or overseas contact details for the potential participant, or if the deceased patient had only had contact with an outpatient clinic, or place of death was not clearly recorded.\u003c/p\u003e\u003cp\u003eAn invitation to participate in the anonymous online survey was sent by mail to participants who met the inclusion criteria. For each deceased person one survey was sent to a family member, the person listed as the main contact Participants unable to take part in the online survey were invited to document their responses by phone. Two bereaved participants reported requiring an interpreter for healthcare discussions but were able to undertake the survey requirements themselves.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical Methods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDescriptive statistics for primary and secondary outcomes were presented for the total sample and for comparison groups formed based on patient characteristics and key participant responses. Independent Z-Test tests were used to test the significance of the differences between percentages for selected columns, a test between independent proportions. Statistical significance was declared when computed p-values were \u0026lt; 0.05. Continuous data are reported using mean and standard deviation and categorical data are reported using frequencies and percentages. In the analysis each question was run against every other question in a univariate analysis. This paper reports associations which were statistically and clinically significant by the investigator team.\u003c/p\u003e\u003cp\u003eAll statistical analysis was performed using Wincross V15 (The Analytical group, Scottsdale, AZ 85260).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFor this study, 293 survey responses were received, with a response rate of 15.7%. This article reports the results from this study which relate to TIC, ACP and their relationship to grief.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1 shows a flowchart of participation and Table 1 displays demographic information. Table 2 outlines the survey results which give context to the circumstances of deaths, involvement in ACP, and bereaved participants reports of their own involvement in decision making in the last 3 months of life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eInsert Table 1\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eInsert Table 2\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFigure 2 displays the ratings that bereaved participants gave when asked to consider their contact with healthcare workers in the months prior to the death in relation to the principles of TIC. These results show high levels of bereaved participants reporting that they felt safe, that they could trust HCW, that staff collaborated with them, gave them choices and listened to them.\u003c/p\u003e\n\u003cp\u003eThere were associations between reports of care provision in line with the principles of TIC, and family members being involved in decisions at the level they wanted to be in the last 3 months of life. Of those participants who reported involvement in decisions at the level they wanted to be, 40.5% strongly agreed that in months prior to the death that they felt staff listened, 41.7% strongly agreed that staff gave choices where possible, 41.6% strongly agreed that staff collaborated about care and plans, 45.7% strongly agreed that they felt they could trust HCW, and 57.4% strongly agreed that they felt safe when interacting with HCW. These results reached statistical significance (p\u0026lt;0.05). While large proportions of respondents also agreed that care in the months prior to the death was in line with TIC principles, this was only statistically significant (p\u0026lt;0.05) for feeling safe when interacting with HCWs (33.3%), feeling they could trust HCWs (41.4%),%) that HCWs collaborated with them (39.1%) and that HCW listened to them (39.3%).\u003c/p\u003e\n\u003cp\u003eFigure 2 also shows the ratings bereaved participants gave when reflecting on their experience of ACP discussions in relation to the principles of TIC. These results indicated even stronger levels of alignment with TIC principles.\u003c/p\u003e\n\u003cp\u003eThere were strong associations (p\u0026lt;0.05) between reports of ACP discussions being held in line with the principles of TIC, and bereaved family members being involved in decisions at the level they wanted to in the last 3 months of life. Of those bereaved family members who agreed that they were involved in decisions as much as they wanted to be, 51.7% strongly agreed that staff listened to them during discussions about Advance Care Planning, 44.0% strongly agreed that staff gave choices about how the discussions were held, and 49.6% reported that staff held the ACP discussion in a collaborative manner.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 displays results relating to participants reporting their perception of the impact of ACP discussions on their grief. Participants who had been involved in ACP discussions (n=138) were asked if they felt the discussion had impacted on their grief. 38.4% reported that ACP discussions had impacted their grief positively, 8.7% a negative impact, 30.4% no impact and 22.5% were not sure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eInsert Table 3\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWhen examining variables which could influence the impact ACP discussions had on later experiences of grief, care in line with a trauma-informed approach was found to have the strongest association with ACP impacting positively on grief. The strongest predictors of whether a bereaved person felt that ACP discussions had a positive impact on their grief was where they strongly agreed that ACP discussions were held by staff \u0026nbsp;in a collaborative way (this group had increased reports of positive impact to 49.2%), or strongly agreed that staff gave them choices in how the discussion was held (this group had increased reports of positive impact to 50%), or where they strongly agreed that staff listened (this had group increased reports of positive impact to 50.8%). TIC was the strongest association as compared with the other variables such as the diagnosis of the deceased or which healthcare provider led the ACP discussions. \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results show a strong association between care being provided in line with the principles of TIC and family members being involved in decisions at the level they wanted to be in the last 3 months of life. Given that many people within the general population have been exposed to trauma during their lifetime[10, 11] and high levels of trauma exposure for those in healthcare settings[11, 28, 35] the reasoning underpinning a trauma-informed approach to the care in the last months of life is clear.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of our study particularly highlight the positive impacts that ACP can have on bereavement experiences. 38.4 % of participants involved in ACP reported the discussions had a positive impact on their grief. These results significantly improved if participants reported that ACP discussions were held in line with TIC principles, especially for those who strongly agreed the discussion was collaborative, that they were given choices, and were listened to. Findings contribute to a new, self-reported perspective from bereaved family members on the connection between their participation in ACP discussions and subsequent impact on their grief. This resonates with the work of previous studies that report ACP possesses benefits for caregivers in bereavement, such as lower stress, depression, anxiety and posttraumatic distress, and decreased grief scores[6, 9, 31, 32]. Given that participants may have interpreted ACP to included broader planning discussions, these positive results indicate likely beneficial impacts on grief from drawing on a trauma informed approach for any discussions regarding serious illness and planning.\u003c/p\u003e\n\u003cp\u003eOur study contributes to the existing literature demonstrating the ways in which ACP can promote healthy bereavement experiences. Previous studies posit that ACP assists with grief and bereavement by increasing family knowledge and understanding of patients\u0026rsquo; wishes with possible subsequent reduced distress in bereavement[6, 31], along with reducing decision burden and improved satisfaction with the quality of death[6]. Falzarano and colleagues consider that completion of an Advance Care Directive (ACD) may help with terminal illness acknowledgement for patients and families, increasing carer\u0026rsquo;s mental preparation for the death, perhaps encouraging improved bereavement outcomes[9]. This preparedness includes the domains of information, emotional preparation and pragmatic preparation[3]. ACP discussions can assist with information-based preparation through education about the illness and its expected progression. These discussions can subsequently equip families for the emotional adjustment over time, attending to relational aspects of death preparation and prompting important conversations and pragmatic preparations such as legal, financial and funeral planning[8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA trauma-informed approach to ACP enhances potential positive impacts in bereavement. Waldrop and McGinley note however that communication gaps can be left if a check box approach to documents is relied on for EOL preparation for caregivers[37]. They advocate ACP discussions which consider the whole-of-life context of a person and their family, their goals and their values. These create opportunities for open discussions with family, exploring distress and discomfort, teaching and preparing in order to promote understanding of their situation and facilitate coping[18]. A systematic review of evidence on ACP tools also notes a shift from a focus on preferences for specific treatments to a greater emphasis on values-based discussions[20]. \u0026nbsp;These holistic approaches to ACP and EOL conversations can be an important part of death preparedness for caregivers[8]. A trauma-informed approach to ACP can create a space where these holistic discussions feel safe and possible and can assist clinicians in how and when to hold these conversations. Our results show the positive impacts that this trauma-informed approach to ACP discussions can have on later grief.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe approaches of ACP and TIC are complementary. A recent review of the evidence on ACP outlines the core elements of ACP as including: Maximizing the person\u0026rsquo;s ability to engage; Exploring their readiness to engage and individualising the process; Exploring the person\u0026rsquo;s understanding of their situation; Exploring patient health related experiences, personal values, concerns and their personal goals; Providing education; Clarifying goals and checking whether these are realistic; Discussing involving a personal representative and their level of involvement; and, explaining that goals and preferences can change (emphasising ACP as a process)[26]. This approach works well when underpinned by trauma-informed care principles which focus on safety in the environment and psychological safety in the discussion, trustworthiness and transparency, collaboration and mutuality, and an empowering approach to discussions that promotes choice and truly fosters the voice and input of consumers and families[4, 27].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings show the benefit of using a trauma-informed approach in ACP. Table 4 provides a proposed framework translating these ideas from abstract concepts into practice. While TIC aligns with the principles of palliative care, patient centred care and ACP, the smaller but significant minority of respondents who reported that their ACP discussions did not fit with TIC principles points to a need to a universal approach and education to support this. A trauma-informed approach can enhance the provision of patient centred care. We advocate for this proposed framework to be incorporated into ACP education. The framework draws on the practical trauma-informed models of Dhawan and LeBlanc for shared decision making with racial minorities in a hematologic setting, and Brown and colleagues work on trauma-informed palliative medicine[4, 7], synthesising and applying these principles in relation to ACP. \u0026nbsp;The framework aims to level the power differences that exist in healthcare due to the specialist knowledge of HCWs[29] which is especially important for those who may have experienced exploitation of power through interpersonal violence[1]. Consideration has been given to maximising choice for patients and families, as our results show that reports of being offered choices about ACP discussions were lower than for the other TIC domains. This perceived lack of choice may be due to restrictions on choices that can be offered, for example when offering resuscitation isn\u0026rsquo;t a medically appropriate option, or when circumstances restrict choice about timing.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eInsert Table 4\u003c/u\u003e\u003c/p\u003e\n\u003ch2\u003eImplications for practice and future research:\u003c/h2\u003e\n\u003cp\u003eThis study illustrates potential benefits of using a trauma-informed approach in ACP. The concepts of TIC should underpin ACP practice as shown in our proposed framework, which can be used in education for HCWs on ACP processes and communication, and could be used to guide all serious illness conversations Further research is required into the practical applications of a trauma-informed approach in ACP, EOL and palliative care. The associations found in our results could be further investigated through qualitative and quantitative research. \u0026nbsp;Attention is required in future research to the experiences of patients and families of Trauma-informed Care in these settings, especially for those who have had past experiences of trauma.\u003c/p\u003e\n\u003ch2\u003eStrengths and limitations\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe strengths of this study include a focus on lived experience, including contributions of consumer co-investigator C.T, as well as the project\u0026rsquo;s development and analysis being informed by a multidisciplinary approach. Limitations of our study include a lack of specific inclusion of Culturally and Linguistically Diverse and Aboriginal and Torres Strait islander voices in the development of the study, and in respondents. Future research could include translation of materials to be more inclusive. Responses may also have been impacted by memory or recall bias given that some respondents were completing the survey over a year past the time of death. The generalisability of our data could have been increased by the inclusion of other institutions, given our sample is from one LHD, and a higher response rate. It is known, however, that survey response rates for sensitive surveys such as those in bereavement tend to be lower than with other populations[2, 13]. This lower response rate meant that some categories had only a small number of respondents which reduced our ability to determine if there was a significant association for some questions, however any results that were reported as significant had sufficient numbers for statistical analyses. A lower response rate increases the possibility that there may be bias in the sample, as such it would be ideal to repeat this survey in other settings with a broader sample. The time period of our survey also included periods impacted by COVID-19 and visiting restrictions in health services which impacted care systems and access to support. Despite the challenges of this period, most participants still reported experiences of care in line with TIC principles.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of this study show that when care is provided in line with the principles of a trauma-informed approach, family and carers are more likely to report being involved in decision making in the last months of life at a level they wanted to be. It was also demonstrated that the potential positive impacts of ACP discussions on grief after death increase markedly where the discussions were held in strong alignment with principles of trauma-informed care. Our proposed framework shows how these TIC principles can be used in practice in ACP. Findings can inform education for healthcare workers on trauma-informed approaches in palliative and end of life care, and ACP interventions. Further research is required into the practical application of trauma-informed approaches in these areas.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis work was supported by funding received from Sydney LHD (no grant number). This support is gratefully acknowledged. The funder had no direct role in the design of the study; analyses or interpretation of data; writing of the manuscript; or the decision to publish the results.\u003c/p\u003e\n\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. The study was approved by the Concord Repatriation General Hospital Human Research Ethics Committee (reference 2022/ETH01743).\u003c/p\u003e\n\u003ch2\u003eConsent to participate\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare they have no relevant financial or non-financial interests, or relevant disclosures.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAaron E, Criniti S, Bonacquisti A, Geller PA (2013) Providing sensitive care for adult HIV-infected women with a history of childhood sexual abuse J Assoc Nurses AIDS Care 24: 355-367\u003c/li\u003e\n\u003cli\u003eAoun SM, Breen LJ, Howting DA, Rumbold B, McNamara B, Hegney D (2015) Who needs bereavement support? A population based survey of bereavement risk and support need PLoS One 10: e0121101\u003c/li\u003e\n\u003cli\u003eBoerner K, Mancini AD et al (2013) On the nature and prevalence of uncomplicated and complicated patterns of grief. In: Schut M, Schut, H, Van Den Bout, J (ed) Complicated Grief: scientific foundations for healthcare professionals. Routledge, London, pp. 55-67.\u003c/li\u003e\n\u003cli\u003eBrown C, Peck S, Humphreys J, Schoenherr L, Saks NT, Sumser B, Elia G (2020) COVID-19 Lessons: The Alignment of Palliative Medicine and Trauma-Informed Care J Pain Symptom Manage 60: e26-e30\u003c/li\u003e\n\u003cli\u003ede Groot JM, Fehon DC, Calman L, Miller DS, Feldstain A (2023) Trauma-informed palliative care is needed: A call for implementation and research Palliat Med 37: 1470-1473\u003c/li\u003e\n\u003cli\u003eDetering KM, Hancock AD, Reade MC, Silvester W (2010) The impact of advance care planning on end of life care in elderly patients: randomised controlled trial BMJ 340: c1345\u003c/li\u003e\n\u003cli\u003eDhawan N, LeBlanc TW (2022) Lean Into the Uncomfortable: Using Trauma-Informed Care to Engage in Shared Decision-Making With Racial Minorities With Hematologic Malignancies Am J Hosp Palliat Care 39: 4-8\u003c/li\u003e\n\u003cli\u003eDurepos P, Sussman T, Ploeg J, Akhtar-Danesh N, Punia H, Kaasalainen S (2019) What Does Death Preparedness Mean for Family Caregivers of Persons With Dementia? Am J Hosp Palliat Care 36: 436-446\u003c/li\u003e\n\u003cli\u003eFalzarano F, Prigerson HG, Maciejewski PK (2021) The Role of Advance Care Planning in Cancer Patient and Caregiver Grief Resolution: Helpful or Harmful? Cancers (Basel) 13\u003c/li\u003e\n\u003cli\u003eFrissa S, Hatch SL, Fear NT, Dorrington S, Goodwin L, Hotopf M (2016) Challenges in the retrospective assessment of trauma: comparing a checklist approach to a single item trauma experience screening question BMC Psychiatry 16: 20\u003c/li\u003e\n\u003cli\u003eGanzel BL (2018) Trauma-Informed Hospice and Palliative Care Gerontologist 58: 409-419\u003c/li\u003e\n\u003cli\u003eGries CJ, Engelberg RA, Kross EK, Zatzick D, Nielsen EL, Downey L, Curtis JR (2010) Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU Chest 137: 280-287\u003c/li\u003e\n\u003cli\u003eHunt KJ, Shlomo N, Addington-Hall J (2013) Participant recruitment in sensitive surveys: a comparative trial of \u0026apos;opt in\u0026apos; versus \u0026apos;opt out\u0026apos; approaches BMC Med Res Methodol 13: 3\u003c/li\u003e\n\u003cli\u003eJohnson CC, Suchyta MR, Darowski ES, Collar EM, Kiehl AL, Van J, Jackson JC, Hopkins RO (2019) Psychological Sequelae in Family Caregivers of Critically III Intensive Care Unit Patients. A Systematic Review Ann Am Thorac Soc 16: 894-909\u003c/li\u003e\n\u003cli\u003eJohnson SB, Butow PN, Bell ML, Detering K, Clayton JM, Silvester W, Kiely BE, Clarke S, Vaccaro L, Stockler MR, Beale P, Fitzgerald N, Tattersall MHN (2018) A randomised controlled trial of an advance care planning intervention for patients with incurable cancer Br J Cancer 119: 1182-1190\u003c/li\u003e\n\u003cli\u003eKross EK, Engelberg RA, Gries CJ, Nielsen EL, Zatzick D, Curtis JR (2011) ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU Chest 139: 795-801\u003c/li\u003e\n\u003cli\u003eMah K, Swami N, Pope A, Earle CC, Krzyzanowska MK, Nissim R, Hales S, Rodin G, Hannon B, Zimmermann C (2022) Caregiver bereavement outcomes in advanced cancer: associations with quality of death and patient age Support Care Cancer 30: 1343-1353\u003c/li\u003e\n\u003cli\u003eMcGinley JM, Waldrop DP (2020) Navigating the Transition from Advanced Illness to Bereavement: How Provider Communication Informs Family-related Roles and Needs J Soc Work End Life Palliat Care 16: 175-198\u003c/li\u003e\n\u003cli\u003eMorris SE, Nayak MM, Block SD (2020) Insights from Bereaved Family Members about End-of-Life Care and Bereavement J Palliat Med 23: 1030-1037\u003c/li\u003e\n\u003cli\u003eMyers J, Cosby R, Gzik D, Harle I, Harrold D, Incardona N, Walton T (2018) Provider Tools for Advance Care Planning and Goals of Care Discussions: A Systematic Review Am J Hosp Palliat Care 35: 1123-1132\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Malley KA, Etchin AG, Auguste EJ, Kaiser AP, Korsun L, Weiskittle RE, Bashian HM, Sager ZS, Moye J (2023) Advancing Trauma-Informed Care Education for Hospice and Palliative Staff: Development and Evaluation of Educational Videos J Hosp Palliat Nurs 25: 224-233\u003c/li\u003e\n\u003cli\u003eOverbeek A, Korfage IJ, Hammes BJ, van der Heide A, Rietjens JAC (2019) Experiences with and outcomes of Advance Care Planning in bereaved relatives of frail older patients: a mixed methods study Age Ageing 48: 299-306\u003c/li\u003e\n\u003cli\u003ePenny A, Relf M (2017) A guide to commissioning bereavement services in England. In: Editor (ed)^(eds) Book A guide to commissioning bereavement services in England. National Bereavement Alliance, City.\u003c/li\u003e\n\u003cli\u003eReeves E (2015) A synthesis of the literature on trauma-informed care Issues Ment Health Nurs 36: 698-709\u003c/li\u003e\n\u003cli\u003eRicks-Ahearn E (2020) Practice Considerations for Trauma-Informed Care at End of Life Journal of Social Work in End-of-Life \u0026amp; Palliative Care: 1-17\u003c/li\u003e\n\u003cli\u003eRietjens J, Korfage I, Taubert M (2021) Advance care planning: the future BMJ Support Palliat Care 11: 89-91\u003c/li\u003e\n\u003cli\u003eSAMSHA (2014) SAMHSA\u0026rsquo;s Concept of Trauma and Guidance for a Trauma-Informed Approach. In: Editor (ed)^(eds) Book SAMHSA\u0026rsquo;s Concept of Trauma and Guidance for a Trauma-Informed Approach. Substance Abuse and Mental Health Services Administration, City.\u003c/li\u003e\n\u003cli\u003eSanderson C, Lobb EA, Mowll J, Butow PN, McGowan N, Price MA (2013) Signs of post-traumatic stress disorder in caregivers following an expected death: a qualitative study Palliat Med 27: 625-631\u003c/li\u003e\n\u003cli\u003eSeng JS, Hassinger JA (1998) Relationship strategies and interdisciplinary collaboration. Improving maternity care with survivors of childhood sexual abuse J Nurse Midwifery 43: 287-295\u003c/li\u003e\n\u003cli\u003eSeow H, Bainbridge D, Brouwers M, Pond G, Cairney J (2017) Validation of a modified VOICES survey to measure end-of-life care quality: the CaregiverVoice survey BMC Palliat Care 16: 44\u003c/li\u003e\n\u003cli\u003eSong MK, Ward SE, Fine JP, Hanson LC, Lin FC, Hladik GA, Hamilton JB, Bridgman JC (2015) Advance care planning and end-of-life decision making in dialysis: a randomized controlled trial targeting patients and their surrogates Am J Kidney Dis 66: 813-822\u003c/li\u003e\n\u003cli\u003eSong MK, Ward SE, Lin FC, Hamilton JB, Hanson LC, Hladik GA, Fine JP (2016) Racial Differences in Outcomes of an Advance Care Planning Intervention for Dialysis Patients and Their Surrogates J Palliat Med 19: 134-142\u003c/li\u003e\n\u003cli\u003eStroebe M, Schut H, Stroebe W (2007) Health outcomes of bereavement Lancet 370: 1960-1973\u003c/li\u003e\n\u003cli\u003eSudore RL, Lum HD, You JJ, Hanson LC, Meier DE, Pantilat SZ, Matlock DD, Rietjens JAC, Korfage IJ, Ritchie CS, Kutner JS, Teno JM, Thomas J, McMahan RD, Heyland DK (2017) Defining Advance Care Planning for Adults: A Consensus Definition From a Multidisciplinary Delphi Panel J Pain Symptom Manage 53: 821-832 e821\u003c/li\u003e\n\u003cli\u003eTang ST, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC (2021) Course and predictors of posttraumatic stress-related symptoms among family members of deceased ICU patients during the first year of bereavement Crit Care 25: 282\u003c/li\u003e\n\u003cli\u003eVandenbogaerde I, De Vleminck A, Cohen J, Verkissen MN, Lapeire L, Ingravallo F, Payne S, Wilcock A, Seymour J, Kars M, Gronvold M, Lunder U, Rietjens J, van der Heide A, Deliens L (2022) Advance care planning-family carer psychological distress and involvement in decision making: the ACTION trial BMJ Support Palliat Care \u003c/li\u003e\n\u003cli\u003eWaldrop DP, McGinley JM (2022) Beyond Advance Directives: Addressing Communication Gaps and Caregiving Challenges at Life\u0026apos;s End J Pain Symptom Manage 63: 415-422\u003c/li\u003e\n\u003cli\u003eWen FH, Chou WC, Hou MM, Su PJ, Shen WC, Chen JS, Chang WC, Hsu MH, Tang ST (2022) Associations of death-preparedness states with bereavement outcomes for family caregivers of terminally ill cancer patients Psychooncology 31: 450-459\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cu\u003eTable 1 \u0026ndash; Demographics\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeceased\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 255px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBereaved (participant)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n= 245)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n = 246)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e136 (55.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMale \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e55 (22.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eFemale \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e109 (44.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e190 (77.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNon-Binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eNon-Binary\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eThey used a different term\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eThey used a different term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"9\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n=245)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n = 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e18-29\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e18-29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e30-39\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e30-39\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e8 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e40-49\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e40-49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e27 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e10 (4.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e50-59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e71 (28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e60-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e30 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e60-69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e73 (29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e70- 79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e72 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e70- 79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e52 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e80-89\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e58 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e80-89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e9 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e90+\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e57 (23.3%) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e90+\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSexual orientation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n = 243)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n = 242)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStraight (Heterosexual)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e228 (93.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eStraight (Heterosexual)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e222 (91.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eGay or Lesbian\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eGay or Lesbian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e13 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eBisexual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eBisexual\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eThey used a different term\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eI use a different term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003ePrefer not to answer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003ePrefer not to answer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003ePlace of birth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n = 245)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n = 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e126 (51.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eAustralia\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e180 (73.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eItaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e22 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e14 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eUnited Kingdom\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e21 (8.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eChina\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eGreece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e15 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eNew Zealand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eGreece\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eItaly\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e46 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e29 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMain language at home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n = 245)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n = 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e183 (74.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eEnglish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e227 (92.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eItalian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e16 (6.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eCantonese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eGreek\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e14 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMandarin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCantonese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eGreek\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eMandarin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eItalian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eSpanish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSpanish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e15 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3 (1.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eInterpreter requirement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n = 234)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n =244)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e31 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e203 (86.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e242 (99.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eTime since death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n = 244)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eLess than 2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2-4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e41 (16.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4-6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e42 (17.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e6 months - 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e93 (38.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eLonger than 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e66 (27.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eMain illness (deceased)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e(n =246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCancer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e113 (45.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eHeart Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e26 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eThey were not ill \u0026ndash; died suddenly\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e14 (5.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eLung disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13 (5.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eKidney or Liver Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e11 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eCOVID-19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eInfluenza or Pneumonia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eNeurological disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e8 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e34 (13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eRelationship to deceased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e(n = 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSon/Daughter \u0026ndash;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e112 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSpouse (married or De Facto)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e97 (39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eParent/Parent-in-law\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e15 (6.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eBrother/sister\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eFriend\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eSon-in-law/daughter-in-law\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 2 - Circumstances of death, ACP \u0026amp; involvement in decision making\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eDid they know they were likely to die?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(n = 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eYes, certainly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e101 (41.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eYes, probably\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e62 (25.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eProbably not\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e27 (11%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eNo, definitely not\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e36 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eNot sure\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e20 (8.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eHow long had they been ill before they died?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(n = 242)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eThey were not ill \u0026ndash; they died suddenly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eLess than 24 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e7 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOne day or more but less than a week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e13 (5.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOne week or more but less than a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e33 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOne month or more but less than six months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e50 (20.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eSix months or more but less than a year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e32 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOne year or more\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e98 (40.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eWhere did they die?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(n = 246)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eHome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e52 (21.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eHospital ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e97 (39.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eIntensive Care Unit or\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEmergency Department\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e36 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003ePalliative Care Unit\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e57 (23.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e4 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eWas the person given the opportunity to discuss ACP with their health providers?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(n = 244)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eYes, definitely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e82 (33.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eYes, to some extent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e57 (23.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eNo, they were not given the opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e73 (29.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e32 (13.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"11\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eWho was the main healthcare provider who discussed ACP with them?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(n = 138)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003ePalliative Care Doctor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e40 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eGeneral Practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e28 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eSpecialist Palliative Care Nurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e21 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOther doctor/specialist (e.g. cardiologist)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e14 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOncologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e10 (7.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eCommunity Nurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e6 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eHospital Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eGeriatrician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e5 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e6 (4.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e3 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003eLooking back over the last three months of their life were you involved in decisions as much as you wanted to be?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003e(n = 244)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eI was involved as much as I wanted to be\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e175 (71.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eI would have liked to be more involved\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e46 (18.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eI would like to have to less involved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e1 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e2 (0.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 283px;\"\u003e\n \u003cp\u003eN/A, they were not ill \u0026ndash; they died suddenly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e20 (8.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 3.\u0026nbsp;\u003c/u\u003e\u003cu\u003eBereaved participants reports of ACP discussion impact on their grief since the death\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 332px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReport on impact of ACP discussions on grief since death\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNegative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo impact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNot sure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall results of ACP discussions\u003c/strong\u003e (n=138)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e53 (38.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e12 (8.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e42 (38.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e31 (22.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain provider who discussed ACP:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003ePalliative care doctor (n=40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e19 (47.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e12 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e7 (17.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eGeneral practitioner/primary care physician (n=27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e12 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (3.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e10 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e4 (14.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eSpecialist palliative care nurse (n=21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e6 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e7 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e5 (23.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eOncologist (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eGeriatrician (n=5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eOther doctor/specialist (e.g. cardiologist) (n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e5 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e5 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eCommunity nurse (n=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eHospital nurse (n=5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eOther (n=3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDon\u0026rsquo;t know (n=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain illness of the deceased\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eCancer (n=82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e38 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e6 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e23 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (18.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNon-cancer (n=56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e6 (10.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e19 (33.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e16 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReports of TIC principles during ACP discussions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cem\u003eI felt safe\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\u0026nbsp;\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly Agree (n=79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e37 (46.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e26 (32.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e13 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eAgree (n=41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e12 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e9 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNeutral (n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (21.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e8 (57.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDisagree (n=0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly disagree (n=2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cem\u003eI felt I could trust the healthcare workers\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly Agree (n=67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e30 (44.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e23 (34.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e11 (16.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eAgree (n=53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e22 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (28.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e14 (26.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNeutral (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDisagree (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly disagree (n=5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cem\u003eStaff held the discussion in a collaborative way\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly Agree (n=63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e31 (49.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (1.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e21 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e10 (15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eAgree (n=54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e19 (35.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (7.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e16 (29.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (27.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNeutral (n=16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5 (31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e6 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDisagree (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly disagree (n=3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cem\u003eStaff gave choices about how the discussion was held\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly Agree (n=54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e27 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e17 (31.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e9 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eAgree (n=48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e20 (41.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (31.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e12 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNeutral (n=25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e4 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (16%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e8 (32%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e9 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDisagree (n=6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly disagree (n=2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003e\u003cem\u003eI felt staff listened to me\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly Agree (n=65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e33 (50.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1 (1.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e22 (33.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e9 (13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eAgree (n=50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e17 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e15 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e14 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eNeutral (n=17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e5 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e3 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e7 (41.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eDisagree (n=1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 235px;\"\u003e\n \u003cp\u003eStrongly disagree (n=3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e2 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e1 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTable 4 \u0026ndash; A framework for a trauma-informed approach to Advance Care Planning discussions.\u003c/u\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Principles for TIC interventions\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(SAHMSA 2014 and Brown 2020)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinician actions in ACP practice\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Brown 2020, Dhawan 2021)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSafety:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePromote physical safety in the environment and psychological safety in relationships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eCommunicate the intention to discuss Advance Care Planning (aim to flag this prior to the discussion).\u003c/li\u003e\n \u003cli\u003eCommunicate what to expect during the discussions.\u003c/li\u003e\n \u003cli\u003eClarify patient preferences about who they would like to be present during particular discussions.\u003c/li\u003e\n \u003cli\u003eBe aware of nonverbal cues for anxiety or distress and respond (explore concerns, provide support and reassurance, adapt as required, pause discussion if needed and return at a later date).\u003c/li\u003e\n \u003cli\u003eHold discussion in an appropriate environment allowing the option for planned discussions in privacy where possible.\u003c/li\u003e\n \u003cli\u003eAllocate appropriate time so that the conversation in not rushed\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTrustworthiness \u0026amp; Transparency:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eProvide consistent information and build rapport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eProvide honest information about the illness and care options in accordance with individual preferences as expectations and preferences may vary. This may include the rate and quantity of information.\u003c/li\u003e\n \u003cli\u003eContinual rapport building (emphasising ACP as a process)\u003c/li\u003e\n \u003cli\u003eAcknowledge the uncertainty of illness and reassure of ongoing support and care.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeer Support:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eIncrease recovery and healing by sharing of stories and lived experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003ePromote connection with others e.g. asking \u0026ldquo;Who else might you talk to about your preferences/wishes/this conversation?\u0026rdquo;\u003c/li\u003e\n \u003cli\u003eProvide peer support options if indicated\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCollaboration and Mutuality\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003ePromote sense of control by partnering and levelling power differences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eRespect that patients can have all the facts (if they want them) and are able to make decisions.\u003c/li\u003e\n \u003cli\u003eElicit and address patient concerns\u003c/li\u003e\n \u003cli\u003eWith consent encourage involvement of their family/a support person in decisions and plans.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSeek consent to allow discussions to occur with their family/support person to support the ongoing process\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmpowerment, Voice, and Choice\u003c/strong\u003e:\u003c/p\u003e\n \u003cp\u003eFoster resilience by encouraging autonomy and use of internal strengths and resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eIntroduce the idea of ACP early, to allow for patient to take part in the discussion when ready (if circumstances allow).\u003c/li\u003e\n \u003cli\u003eAsk patients who they would like present for ACP discussions.\u003c/li\u003e\n \u003cli\u003eAsk patients and families about the level of involvement they want in the process of decision making.\u003c/li\u003e\n \u003cli\u003eUse language that can be easily understood.\u003c/li\u003e\n \u003cli\u003eListen to patient and family concerns and respond.\u003c/li\u003e\n \u003cli\u003eEmphasise that ACP is an ongoing process, and patients can change their minds or revisit discussions.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural, Historical, and Gender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIssues:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eReduce re-traumatization and increase healing and recovery by identifying and considering intersectional identities (noting that different aspects of a person\u0026apos;s identity may increase their risk of encountering forms of marginalisation or discrimination e.g. age, gender, sexual orientation etc.).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eApproach patients with curiosity rather than assumptions based on cultural/gender stereotypes. Gently explore their history and story.\u003c/li\u003e\n \u003cli\u003eUnderstand that trauma relating to these issues are key risk factors for recurrent trauma.\u003c/li\u003e\n \u003cli\u003eIf a history of trauma is disclosed, offer options for support and explore with the person what their past experience might mean for them in terms of the care and support they require in future. Check in with the person afterwards to see if they require any further support.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"trauma informed care, advance care planning, grief, bereavement, end-of life-care","lastPublishedDoi":"10.21203/rs.3.rs-7285816/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7285816/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose \u003c/strong\u003e- Application of a Trauma-Informed Care (TIC) approach in palliative and end-of-life care is recent and under-researched. This study aimed to describe the experience of people bereaved following a death in a Local Health District. This included exploring the relationship between ACP and bereavement and whether care provided was consistent with TIC principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003e– Invitations for an online survey were sent to bereaved Next of Kin of adult patients who had died in a metropolitan health district in Australia between September 2021 and November 2022. Data were analysed using descriptive statistics and a Z test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003e– Response rate was 15.7% (n=293). Of participants involved in ACP discussions, 38% reported a positive impact on their post-death grief. Analysis against all variables showed the strongest association for positive impacts of ACP on grief where discussions were held in line with principles of TIC. \u0026nbsp;Associations were also shown between care provision in line with TIC and family being involved in decisions at the level they wanted to be, in the last 3 months of life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003e- A trauma-informed approach to ACP has significant positive impacts on family being involved in decisions at the level they wanted to be, and on their later grief. These results contribute a new perspective from bereaved family members reporting on the impact ACP discussions had on subsequent grief experiences, demonstrating the benefits of a Trauma-Informed approach in ACP. The principles of TIC should be used to underpin ACP practice, and education for healthcare professionals on ACP.\u003c/p\u003e","manuscriptTitle":"Trauma-Informed Care, Advance Care Planning and grief – integrating approaches to enhance care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 18:55:02","doi":"10.21203/rs.3.rs-7285816/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a22a093c-8da1-42f0-b14b-7fd90c5adb3b","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-10T12:39:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-26 18:55:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7285816","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7285816","identity":"rs-7285816","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}