Supplementary Material for: Preferences for Advance Care Planning in Patients with End-stage Kidney Disease: A Cross-sectional survey amongst Nephrology healthcare providers in a Tertiary Care Center in India.

Introduction:
Advance care planning (ACP) is essential in managing patients with end-stage kidney disease (ESKD), yet its integration into clinical practice remains limited, particularly in low- and middle-income countries. This study explores the preferences, attitudes and perceived barriers of nephrology healthcare providers towards ACP for patients with ESKD in a tertiary care centre in India.
Methods:
A cross-sectional survey was conducted among nephrology healthcare providers at a tertiary care centre in India. The survey, developed from literature reviews and pretested, covered demographics, ACP knowledge and attitudes, current practices, and perceived barriers and facilitators. Data collection occurred from September 2022 to March 2023. Quantitative data were analyzed descriptively, and qualitative data through thematic analysis.
Results:
A total of 50 healthcare providers participated. While 36% acknowledged the importance of ACP, only 8% routinely engaged in ACP discussions. Major barriers included inadequate training (22%), lack of awareness about the importance of discussing ACP amongst stakeholders (20%), cultural barriers (18%), lack of time (14%), and the absence of institutional protocols for discussion on ACP (14%). Additional barriers included instances where families withhold health information from patients due to fear of losing hope (16%) and patient/family discomfort in discussing ACP (12%). Providers expressed a need for structured ACP protocols and educational programs.
Conclusion:
Despite recognizing its importance, ACP is underutilized in the care of patients with ESKD in India. Addressing the identified barriers through targeted interventions may enhance ACP practices and improve patient outcomes.