Discussion

Investigating the perspective of hospital HCPs is essential to understand the state of the art of ACP in hospital clinical practice and which factors should be considered to increase its implementation.

The main results of this study are that, with the exception of those working in Palliative Care, only a minority of hospital HCPs had some education or personal experience with ACP discussion. Nevertheless, most HCPs were aware of ACP and had a sound knowledge of its key elements, with the exception of ACP legal requirements. ACP is viewed with favor and considered by the majority of HCPs as part of their duty. However, ACP is seldom offered to patients, and is not always documented, the main barriers being a lack of clarity regarding its practical implementation and correct timing. Overall, physicians, residents, nurses and physiotherapists showed similar knowledge and attitudes toward ACP, but we found inter-specialty differences. Comparing education and discussion levels across care specialties, we observed an overlap among all HCPs, while higher levels of discussion were generally observed among physicians, though the magnitude of the gap differed across care specialties.

Our results show a considerably greater awareness of ACP compared with a previous study carried out in Italian nursing homes (in which 29.7% of participants reported having heard of ACP) (Ottoboni et al. Reference Ottoboni, Chattat and Camedda2019). However, still only a minority of hospital HCPs, including residents, had some education, mainly theoretical, and experience with ACP. This finding is in line with studies carried out in other countries (Chandar et al. Reference Chandar, Brockstein and Zunamon2017; Schichtel et al. Reference Schichtel, Wee and MacArtney2019; Ashana et al. Reference Ashana, D’Arcangelo and Gazarian2021; Martina et al. Reference Martina, Lin and Kristanti2021) and indicates that, despite the legal regulation of ACP, both university and healthcare systems underwent delays in integrating legislative changes into education and hospital practice. ACP seems to be more integrated into the curriculum and clinical practice of only Palliative Care HCPs, in line with their vocation in managing sensitive conversations and exploring patients’ end-of-life preferences (Ferrell et al. Reference Ferrell, Twaddle and Melnick2018).

Despite their familiarity with the key elements of ACP, in line with studies carried out in other countries and care settings (Yee et al. Reference Yee, Seow and Tan2011; Kermel-Schiffman and Werner Reference Kermel-Schiffman and Werner2017; Shepherd et al. Reference Shepherd, Waller and Sanson-Fisher2018; Hooper et al. Reference Hooper, Sabatino and Sudore2020; Martina et al. Reference Martina, Lin and Kristanti2021), HCPs were less knowledgeable regarding legal aspects, suggesting an ongoing challenge in bridging the gap between legal and medical perspectives in ACP (Hooper et al. Reference Hooper, Sabatino and Sudore2020). The main misconceptions concerned ACP documentation and its binding value and may represent a concrete barrier to ACP implementation in clinical practice, since confusion concerning how to implement the law in practice creates uncertainty (Ke et al. Reference Ke, Hu and Takemura2019; Maffoni et al. Reference Maffoni, Argentero and Giorgi2020; Mohan et al. Reference Mohan, Sacks and O’Malley2021).

We found that only around one third of HCPs (44% of physicians) had cared for a patient with ACP during the past year, and that, in line with studies carried out in other countries, most hospitalized patients were not offered ACP discussion (Glaudemans et al. Reference Glaudemans, Moll Van Charante and Willems2015; Knight et al. Reference Knight, Malyon and Fritz2020; Ashana et al. Reference Ashana, D’Arcangelo and Gazarian2021). A gap between favorable attitudes of HCPs toward ACP and limited ACP implementation was found by previous studies carried out since Law 219/17 entered into force. HCPs viewed ACP as a useful tool for aligning the care provided with patients’ preferences and improving communication between healthcare providers, patients, and families; however, these favorable attitudes did not result in consistent implementation of ACP in clinical practice, mainly due to a lack of knowledge and training among HCPs, a lack of standardized procedures, little awareness on the part of the general population, and cultural or religious influences (Maffoni et al. Reference Maffoni, Argentero and Giorgi2020; Testoni et al. Reference Testoni, Bortolotti and Pompele2020; Cipolletta and Reggiani Reference Cipolletta and Reggiani2021; Porteri et al. Reference Porteri, Ienco and Piccinni2024). At an international level, several barriers to ACP implementation in hospitals have been reported, including cultural factors, role ambiguity, lack of time, discomfort with end-of-life themes, and concerns over patients’ reactions (Hsieh et al. Reference Hsieh, Huang and Tung2019; Ashana et al. Reference Ashana, D’Arcangelo and Gazarian2021; Martina et al. Reference Martina, Lin and Kristanti2021; Westbye et al. Reference Westbye, Rostoft and Romøren2023). In our study, half of the participants indicated that barriers to ACP existed in their healthcare organization, and among the main barriers were difficulty understanding the right time for ACP discussion and a lack of clear procedures for its operational implementation, which may be worsened by the lack of knowledge of existing procedures at the hospital level reported by half of the HCPs.

Despite the clear provisions of Law 219/17, there are no national guidelines for ACP in Italy, and it was argued that much is left to the “good will” of the single HCP (Cipolletta and Reggiani Reference Cipolletta and Reggiani2021). On the contrary, the ACP application requires institutional commitment and well-defined procedures to embed ACP into daily workflows (Gilissen et al. Reference Gilissen, Pivodic and Gastmans2018, Reference Gilissen, Pivodic and Wendrich-van Dael2019). Professional guidelines and hospital procedures should also address ACP timing. With this regard, even if it remains challenging to determine a clear threshold for discussions to be initiated (Knight et al. Reference Knight, Malyon and Fritz2020; Westbye et al. Reference Westbye, Rostoft and Romøren2023), recent studies suggest that patients would prefer ACP conversations to be initiated earlier than in current practice (Zhu et al. Reference Zhu, Rietjens and van Delden2025).

One of the main aims of C.OP.E.R.NI.CO. was to compare HCPs with different professional roles. We found that, despite significant differences in almost all personal and professional characteristics, including ACP education and experiences, there were few differences concerning ACP knowledge and attitudes across professions. Moreover, even with more uncertainties among medical residents and physiotherapists, very few participants did not recognize ACP as part of their professional duty. This may suggest a widespread acceptance of the ACP construct among hospital HCPs who are in direct contact with patients, while differences concerning experiences with ACP may reflect different role-based responsibilities, differences in clinical tasks, and unequal exposure to ACP education and discussions. Physicians reported the highest level of ACP discussion (57.1%), while only 21.2% of nurses and 22.5% of physiotherapists reported having participated in ACP discussion during the past year, respectively. These findings may reflect the prominent role that Law 219/17 attributes to the physician as the main ACP provider, resulting in a low level of involvement of non-medical HCPs in ACP. Moreover, with regard to nurses, it is possible that our findings were influenced by the large proportion of nurses working in Anesthesia-Intensive Care and Surgery, including the operating room, who may have had little opportunity to discuss ACP despite their greater exposure to ACP and palliative care education. This hypothesis could also explain why, in our survey, nurses were those who were less likely to consider ACP useful for the patients in their care. On the contrary, the results concerning physiotherapists were in line with their lower levels of ACP and palliative care education and the highest proportion of uncertainty regarding whether ACP is part of their professional duty. Future studies are needed to better address this topic.

Findings regarding residents warrant a separate discussion. To our knowledge, this is the first study comparing residents, physicians, and other HCPs. We found that residents reported less ACP training, had more legal misconceptions, were more likely to report inadequate skills, perceived obstacles to ACP in their health organizations, as well as uncertainty regarding the existence of specific procedures in their healthcare organization. These findings support the need for both specific training, including ethical reasoning skill development and supervisor feedback, and structural reforms to better integrate ACP into residents’ clinical practice (Fassier et al. Reference Fassier, Rapp and Rethans2021; Dias et al. Reference Dias, Frutig and Bezerra2023; Bombaci et al. Reference Bombaci, Di Lorenzo and Pucci2024).

Regarding comparison among care specialties, the substantial inter-specialty differences in ACP could be attributed to several reasons, including variations in patient characteristics, in the participants’ clinical roles, or in the communication training backgrounds of the respondents. Considering that we surveyed care specialties in which patients are presumably most likely to need ACP, the variability we found is striking.

Considering hospital HCPs overall, we observed an overlap between education and discussion levels that supports the link between ACP education and ability to engage with ACP in different care specialties (Chandar et al. Reference Chandar, Brockstein and Zunamon2017; Chan et al. Reference Chan, Nhy and Chan2019; Yamamoto et al. Reference Yamamoto, Yonekura and Nakayama2022; Sakamoto et al. Reference Sakamoto, Inokuchi and Iwagami2023; Zhang et al. Reference Zhang, Ng and Sie2025).

Among physicians, we observed a consistent gap in favor of ACP discussion over education, which was especially evident in some care specialties, such as Internal Medicine, in which frail older adults are the main population of patients, Nephrology-Dialysis and Neurology. This suggests that when ACP is required, many physicians adopt informal or experiential approaches. Quality assessment of both the process and the outcomes is necessary to understand the implications of these approaches.

Conversely, in specialties such as Cardiology, Oncology and Hematology, physicians reported both absent or low levels of ACP education and low levels of ACP discussion. We may speculate that additional challenges to ACP associated with specific conditions, including assessing decisional capacity and managing unpredictable disease trajectories or limited continuity of care (Jabbarian et al. Reference Jabbarian, Zwakman and van der Heide2018; Schichtel et al. Reference Schichtel, Wee and MacArtney2019; Ladin et al. Reference Ladin, Neckermann and D’Arcangelo2021; Guccione et al. Reference Guccione, Fullerton and Gough2023; Naik et al. Reference Naik, Ghoshal and Damani2025), may differently influence the implementation process across care specialties. In order to gain better insight into ACP specialty-specific barriers and facilitators, future studies comparing specialties should incorporate narrative, phenomenological, and ethnographic approaches (De Vleminck and Van den Block Reference De Vleminck and Van den Block2023).

Highlighting as it does the unique level of engagement in ACP of HCPs workin in Palliative Care, this study suggests that they may act as catalysts for the development and implementation of hospital-based ACP, helping to translate broadly favorable attitudes toward ACP into more consistent clinical practice, through interventions at different levels. Since palliative care skills are among the main enablers in aiding discussions on ACP (Guccione et al. Reference Guccione, Fullerton and Gough2023), palliative care HCPs may have a primary role in ACP training (Chandar et al. Reference Chandar, Brockstein and Zunamon2017), contributing to interprofessional education from undergraduate curricula onwards to strengthen communication and collaboration (Ke et al. Reference Ke, Hu and Takemura2019). Moreover, they may have a pivotal role in facilitating multidisciplinary meetings of healthcare teams, patients, and families, particularly in complex cases. Finally, based on their greater experience with ACP in the hospital context, palliative care HCPs may have a leading role at the institutional level in the development of local ACP procedures, documentation pathways, and organizational cultures to integrate ACP into routine hospital practice.

The strengths of this study include the high number of participants involved, the inclusion of both physicians and other HCPs, and the variety of care specialties surveyed. However, several limitations of the study should be acknowledged. As this study was conducted in Northern Italy, it does not account for the potential regional differences regarding ACP or palliative care education suggested in previous studies (Bombaci et al. Reference Bombaci, Di Lorenzo and Pucci2024). The large number of participants working in Anesthesia-Intensive Care could have negatively affected the proportion of HCPs who had the opportunity to discuss ACP in clinical practice, since these HCPs often come into contact with patients during a single preoperative consultation or work with patients who are sedated or unable to discuss ACP. Moreover, the use of an anonymous, self-administered online survey, while effective in reaching a large number of participants, may have introduced a self-selection bias, potentially attracting HCPs with a pre-existing interest in or awareness of ACP. A self-selection bias is inherent to any survey of this nature (Hsieh et al. Reference Hsieh, Huang and Tung2019; Dias et al. Reference Dias, Frutig and Bezerra2023; Sakamoto et al. Reference Sakamoto, Inokuchi and Iwagami2023) and may have influenced the high proportion of HCPs with positive attitudes toward ACP, increasing the gap between attitudes and practice. Future research could specifically focus on the perspective of HCPs who are less favorable to ACP. Moreover, while the anonymity and confidentiality assured by the survey design aim to reduce any social desirability bias, they do not eliminate this risk (Chandar et al. Reference Chandar, Brockstein and Zunamon2017; Hsieh et al. Reference Hsieh, Huang and Tung2019; Ke et al. Reference Ke, Hu and Takemura2019; Dias et al. Reference Dias, Frutig and Bezerra2023). Including 4 distinct, well-defined professional groups in the analysis was useful in order to provide a wider picture of different HCPs’ perspectives and experiences with ACP. The inclusion of physiotherapists, in particular, offered original insight. However, due to an insufficient number of respondents from certain professions, which may be greatly involved in ACP (e.g., psychologists), it was necessary to exclude them from the analysis, preventing us from obtaining a more complete picture. Finally, the cross-sectional design does not allow for causal inferences.

Taking these limitations into account, the C.OP.E.R.NI.CO. study provided a picture of ACP in hospital practice in a country where it is formally regulated by law. A large multi-professional population, including little-studied groups such as medical residents and physiotherapists, was surveyed across multiple care specialties, integrating knowledge, attitudes, and experiences that may help to address the issue of why ACP implementation in the hospital setting remains limited.

In summary, this study shows that formal regulation of ACP by law is not per se sufficient to reach desirable levels of ACP education and practice among hospital HCPs, highlighting the importance of investigating HCPs’ attitudes and practices in parallel, as favorable views toward ACP do not always translate into its implementation. Specific ACP theoretical education and practical training are needed and would be welcomed by most hospital HCPs. Special attention should be given to conveying legal concepts and to training residents. Moreover, our results indicate the need not only to develop local procedures (including clear documentation procedures) but also to ensure that they are disseminated adequately. Finally, showing the existence of substantial differences across hospital care specialties, this study suggests the existence of specialty-specific barriers and facilitators that may differentially operate in addition to individual, professional, organizational, and cultural factors in affecting ACP implementation in hospital clinical practice. In this composite scenario, palliative care HCPs may play a pivotal role in helping to translate broadly favorable attitudes toward ACP into more consistent clinical practice through education, clinical leadership, and institutional support and guidance in implementing hospital-based ACP.