Primary Care


i-GAP is a research project that is intended to increase the participation of patients and families in Advance Care Planning (ACP) in primary care settings. Our goal is to improve the quantity and quality of advance care planning in primary care.

Read more about the project and why it's important in Canadian Family Physician.


Did you know? 60% of Canadians want their healthcare provider to give them information about advance care planning, but only 26% of primary care physicians are comfortable having those discussions, and 67% of primary care physicians say they need more resources and information.1,2 Advance Care Planning (ACP) is the process of considering options for future health care decisions and personal care, and the nomination of a substitute decision maker who can speak for them if they cannot speak for themselves.

i-GAP Study Update

Patient Engagement:

The i-GAP project studied over 800 primary care patients in Ontario, Alberta and British Columbia to determine their levels of engagement in various aspects of ACP. 

Our findings:

  • 23% of patients have engaged in all 4 ACP behaviours
  • 15% have not done any ACP
  • 53% of patients have talked to someone about ACP; but only 18% have talked to their family doctors


What doctors say: 

Doctors participating in i-GAP have identified the following barriers to advance care planning in primary care: 

  • Lack of time
  • Lack of patient engagement and their understanding of treatment decisions
  • More public awareness/education needed
  • More tools and resources for healthcare professionals needed


Tool Testing: 

We are evaluating national and provincial tools to determine their impact on patient engagement and to better understand how to use tools most effectively. To date over 300 patients in Alberta, British Columbia and Ontario have been involved in evaluating ACP tools. Tool testing has demonstrated that ACP tools are effective and increase ACP behaviours.



Comments from participants in the i-GAP study: 

  • "I don't want a 'parent' making decisions, I want my voice to be paramount, not their interests. Awareness of the decision and urgency to address today so it is my voice heard. I don't want to be powerless and trapped in a life I don't want to live."
  • "My mind and heart are having a conversation I didn't want to have.  It's a good thing. I need to address this."
  • "I felt good that I had made that decision, that it had been communicated and the rest of the family knows who that person is. I found it helpful and I was appreciative that people are working on this. I have friends who haven't made that decision and say 'my family will know'."
  • "Made me realize that planning for these kinds of events isn't just an insular experience. All of the people who care about you should know so that they understand and are more comfortable with what is taking place so that they can provide support to those who are intimately involved.  It would be sad for me if my friends were saying to my family, "You're making the wrong decision."



Study Tools:



Information Sheet Information Sheet
Poster Poster
Practice Characteristics Chart Abstraction Form
Physician Questionnaire Questionnaire
Nursing and Allied Health Care Professionals Questionnaire  



i-GAP Timeline

October 2014

June 2015


ACP Audit 

We conducted an ACP audit with 20 family practices across Canada (AB, BC, ON ) to assess:

  • Levels of ACP knowledge and engagement among patients in primary care by administering the ACCEPT survey and
  • Barriers to ACP among physicians, nurses and allied health professionals in primary care by administering the DECIDE survey.

ACP Tool Testing 

We began evaluating a suite of tools to test:

  1. Acceptability, feasibility and clinical sensibility and
  2. Efficacy for increasing ACP behaviour.

ACP Tool Implementation 

We will begin testing a Model for Implementing ACP in Primary Care (currently referred to as a Care Pathway).  


Project Lead: Michelle Howard

BA (Hons) (McMaster), MSc (University of Toronto), PhD (McMaster), Assistant Professor Department of Family Medicine, McMaster Univeristy, Research Lead, Division of Palliative Care

Michelle Howard is an Assistant Professor in the Department of Family Medicine.  She has an MSc in Epidemiology from the University of Toronto and a PhD in Health Research Methodology from McMaster University.  Her research interests are in health service delivery in primary care and palliative care including evaluating practice organization, interprofessional teams, the role of electronic personal health records, and quality improvement programs and measures for primary care. She is also a tutor for Evidence-Based Medicine in the Family Medicine residency program.

Special Interests 

Primary care organization

Quality improvement

Interprofessional primary care

Palliative care




Read about Dr. Carrie Bernard, a family physician and one of the founding researchers for the i-GAP project.

Read Dr. Amy Tan's story about palliative care (Dr. Tan is a member of the i-GAP steering committee)

Read the i-GAP team's opinion article in Canadian Family Physician - "Advance Care Planning - let's start sooner"

Read about Dr. Zou and her experience with the i-GAP study.




1. Canadian Hospice Palliative Care Association, The Way Forward Survey: General/Family Practitioners and Nurses in Primary Care, for The Way Forward initiative, Ipsos Reid: 2014.

2. Canadian Hospice Palliative Care Association, What Canadians Say: The Way Forward Survey Report, for The Way Forward initiative, Harris/Decima: 2013.        



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