“Triggering the palliative intent”?: A qualitative implementation evaluation of a prognostication model for advanced dementia (PRO-MADE) in a geriatric tertiary care setting for the integration of early palliative care

Background: Prognostication uncertainty in advanced dementia impedes timely palliative referrals. Despite rapid development of dementia prognostication models, most have not progressed beyond external validation, with implementation in routine clinical practice as part of the electronic medical record system remaining underexplored. Empirical gaps exist in understanding interdisciplinary perspectives from palliative and geriatric specialties regarding implementation complexities of such hospital-based innovations. This formative study evaluated implementation of a validated PROgnostic Model for Advanced DEmentia (PRO-MADE) as a clinical decision support tool in a Singapore tertiary care setting. PRO-MADE informs physicians of patients' one-year mortality risk to initiate end-of-life care plans, including inpatient specialist and community palliative care referrals.

Methods: Focus group discussions and in-depth interviews with key stakeholders were analysed and triangulated through rapid deductive-inductive qualitative approach using template analysis, underpinned by the Consolidated Framework for Implementation Research and its Outcomes Addendum. Through maximum variation purposive sampling, 30 professionals across the hospital and community settings participated in seven focus group discussions and two in-depth interviews. Twelve physician implementers from the geriatric medicine specialty, eight healthcare professionals from the palliative medicine specialty, and 10 community-based multidisciplinary palliative care professionals were involved.

Results: Five main themes characterise the complexities shaping PRO-MADE’s adoption and implementation across key interrelated contextual domains: outer and inner settings (alignment with and operationalisation of palliative care related policies), inner setting and innovation (competing views between disciplines on workflow integrability in clinical practice), inner setting and individuals (alignment of implementation intent with clinical setting; accessibility and adaptation of the electronic medical record system for implementation), and outer setting and individuals (relevance of prognostication for palliative care delivery to patients and families). Findings reflect that implementing prognostication-informed care models involve navigating implementers’ professional role and identity preservation in managing end-of-life care, compatibility with clinical practice, and family’s needs and readiness.

Conclusions: This implementation research study uncovered factors at the structural, disciplinary identity, interprofessional and patient-caregiver-provider levels influencing PRO-MADE’s adoption and implementation for end-of-life care planning and palliative support. Findings suggest the need for targeted implementation strategies, including early stakeholder engagements and adapting integration to clinical settings and patient-family needs to optimise implementation success.

SOURCE: BMC Palliative Care

DOI: https://doi.org/10.1186/s12904-026-02138-5

AUTHORS: Subramaniam A, Tan WS, Tan HTR, Wang Q, Ding YY, Hum A & PRO-MADE Implementation Group