Vicky, this is super nicely written and formatted (which really makes a difference!) As I was reading, I was wondering whether it is possible that there isn't really an advance care planning process in clinics. I agree about the observation, and not sure if you thought of either audio/video-recorded or in person observation of the actual discussions between surgeons and patients - this would be very informative. I would recommend switching the order of your aims so that you observe first, and then interview, so you could ask patients and clinicians about specific visits and what they did / didn't discuss. What do you think?