Drivers and barriers to participate in advance care planning: insights from Chinese community-dwelling older adults

Drivers and barriers to participate in advance care planning: insights from Chinese community-dwelling older adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Drivers and barriers to participate in advance care planning: insights from Chinese community-dwelling older adults Fang Gao, Kun Wang, Li Xiao, Chong Chin Che, Rong Hu, Ping Lei Chui, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7425642/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Advance care planning (ACP) is effective in enhancing the quality of life during older adults’ end-of-life stage. However, ACP remains a novel concept in China, and the inclination of community-dwelling older adults towards ACP participation remains uncertain. Objectives: To explore the factors that promote or hinderparticipating in ACP from the perspectives of Chinese community-dwelling older adults. Design: This was a descriptive qualitative study that incorporated semi-structured interviews. Methods: Purposive sampling was used to enlist a total of 22 older adults residing in four communities in Chengdu, China. The data were transcribed verbatim and analysed using thematic analysis. Results: The analysis identified four main themes and eighteen subthemes that influenced older adults’ participation in ACP. The four themes were: perspective on death, drivers of ACP participation, barriers to participation, and strategies to promote engagement in ACP. Conclusions: This study highlights drivers and barriers to ACP participation among community-dwelling older adults in China, offering valuable insights for developing targeted interventions to support ACP implementation. Enhanced mortality education and involvement of family members play an important role in promoting ACP engagement. advance care planning barrier driver older adults qualitative study Background China has become the largest country with an aging population due to its large population base and low birth rate (Shen et al., 2022). The proportion of people aged 60 and over is expected to increase to 28% (402 million) by 2040 (Organization, 2025). However, the development of end-of-life care has not kept pace with this demographic shift. Deep-rooted cultural taboos surrounding death, underdeveloped legal frameworks, and insufficient institutional support in clinical and community settings continue to impede open conversations about end-of-life medical decisions (Liao et al., 2019). Consequently, many older adults are suffering from excessive or unnecessary medical treatment that is not in line with their wishes (Krakauer, 2024). This not only leads to the inefficient use of medical resources but also imposes significant physical, psychological and economic burdens on both the older adult in question and their families. As humanistic values gain traction and awareness of individual autonomy grows, ensuring dignity and comfort in dying has become a key aspect of successful aging (Jin et al., 2022). Advance care planning (ACP) is the process by which individuals make decisions about their preferences for medical care, including consenting to, refusing, or discontinuing treatment, as well as appointing a surrogate decision-maker (Sudore et al., 2017). ACP has been recognised as an essential aspect of patient-centred and cost-effective end-of-life care (Kelley & Morrison, 2015) and has been widely implemented in many Western countries (Nedjat-Haiem et al., 2018). In contrast, ACP remains relatively unfamiliar in mainland China. A survey in Zhengzhou found that 92.7% of older adults had never heard of ACP (Zhu et al., 2020). Studies in China have primarily focused on patients with advanced cancer, addressing only treatment preferences and attitudes toward death (Han et al., 2018). This narrow focus limits the representativeness of the study findings to the broader community population and neglects the perspectives of community-dwelling older adults, the primary target group for developing ACP. Considering that ACP is a deeply personal and subjective issue, shaped by individual values, beliefs and experiences (Munhall, 2012), integrating the voices of older adults is crucial. Recent evidence suggests that their willingness to engage in ACP is influenced by personal, relational, professional, and policy-related factors (Gao et al., 2024). Capturing these perspectives can enrich our understanding of the drivers and barriers to ACP participation and inform more culturally sensitive practices. Therefore, this study aimed to explore the factors that promote or hinder participating in ACP from the perspectives of Chinese community-dwelling older adults. The research questions were as follows (i) What are the factors that promote community-dwelling older adults' participation in ACP? (ii) What are the factors that hinder community-dwelling older adults' participation in ACP? Methods Design and setting This study employed a descriptive, qualitative approach using individual face-to-face semi-structured interviews to explore drivers and barriers to participate in ACP. The research was carried out in four community health service centers in Chengdu city. The study was presented according to the Consolidated Criteria for reporting Qualitative Research checklist (Tong et al., 2007) (Appendix 1). Participants A purposive sampling method (Daniel, 2019) was used to recruit older adults from community health service centers in Chengdu city. These participants had previously consented and taken part in a survey on readiness toward ACP (Gao et al., 2025) and agreed to share their insights for this study. The inclusion criteria for participation were as follows: aged 60 years or older; a result of the montreal cognitive assessment ≥ 26 (Hu et al., 2013), assessed by trained researchers. The sample size of the qualitative study is determined by data saturation, and no new information emerges from the data collection process. A total of 22 participants were interviewed individually to obtain their perspectives on the factors that promote or hinder participating in ACP. Research team characteristics The research team was exclusively female and consisted of four nurses (GF, WK, XL, and HR), and two nursing lecturers (CPL and CCC). GF was a PhD candidate at XX University, WK, XL and HR were masters, all specialize in nursing and gerontology and have qualitative research training and experience in doing qualitative research. The two team members (CPL and CCC) hold a PhD qualification and have expertise in qualitative research. None of the members of the research team had prior relationship with the respondents. Data collection Data were collected from April 2 to July 2024 using semi-structured, in-depth interviews. All interviews were conducted in Mandarin by GF in a private, quiet room within selected community health service centers at a time convenient for the participants. WK and XL served as observers and were responsible for taking field notes. Each interview lasted approximately 30 to 45 minutes and was audio-recorded with participants’ consent. Notably, no participants dropped out during the interview process, and no repeat interviews carried out. Data collection continued until data saturation was reached. All audio recordings were transcribed verbatim immediately following each interview. The interviews aimed to explore the drivers and barriers of participating3 in ACP among older adults. Demographic information was collected, including age, gender, marital status, education level, religion, monthly income, and self-rated health status. The interview guide was developed by the authors (GF, WK XL, and HR) based on the relevant literature and the study objective was reviewed by CPL and CCC. Two pilot interviews were conducted with older adults who were not included in the final analysis to refine the interview questions and identify any issues. After minor revisions, the finalized interview guide is presented in Table 1 . Table 1 Interview guide. (1) How do you view death? (2) What kind of end-of-life care do you want? (3) How do you think about ACP? (4) Are you willing to participate in ACP? (5) What approach you like to proceed with the ACP? (6) What are your suggestions for promoting ACP in China? Data processing & analysis In this study, all audio-recorded interviews were transcribed verbatim in Chinese within 24 hours of the interviews. Transcriptions were manually completed by the primary researcher (GF), ensuring close engagement with the data. The data were coded by GF and WK independently for each participant in Chinese to retain cultural and linguistic nuances. key quotations were then translated into English using a forward and back-translation process. The initial translation was done by GF, a bilingual researcher trained in qualitative methods, followed by an independent back-translation by CPL, another bilingual translator. Discrepancies were resolved through discussion to ensure conceptual equivalence between the original and translated texts. The data collected were analysed using thematic analysis (Khokhar et al., 2020) in NVIVO 14, following Gibbs (2007) six-step approach. The analysis began with familiarization and initial coding, after which the coded transcripts were compared with the original recordings to ensure accuracy. Transcripts were then returned to participants for member checking; no corrections or comments were received. In the subsequent steps, potential themes were identified, reviewed, and refined through multiple rounds of discussion to ensure clarity, consistency, and representativeness. The final stages involved defining and naming the themes and presenting the findings thematically. This structured and rigorous analytical approach provided an in-depth understanding of the drivers and barriers influencing older adults’ participation in ACP, thereby strengthening the trustworthiness and reliability of the results. Rigor and trustworthiness The trustworthiness of the study was evaluated using four key criteria: credibility, dependability, confirmability, and transferability (Ahmed, 2024). Credibility was strengthened through triangulation. Two independent observers (XL and HR), who did not involvement in data collection, contributed field notes and reviewed the study design, interview procedures, and thematic analysis. The integration of both interview data and observational field notes enabled triangulation, which enriched the interpretation of findings and reduced the risk of bias associated with reliance on a single data source (Ahmed, 2024). Dependability was ensured by maintaining a detailed audit trail documenting all methodological decisions, modifications, and justifications throughout the research process. Furthermore, the research team was divided into two subgroups that independently analysed and compared the data, thereby reinforcing the consistency and reliability of the results (Eryılmaz, 2022). Confirmability was enhanced through member checking, whereby key points from each interview were summarized during and after the session and verified by participants. This allowed respondents to affirm or clarify the researchers’ interpretations, promoting greater objectivity (Ahmed, 2024). Finally, transferability was supported through the use of thick description, providing rich contextual details about the participants and research setting. This approach allows readers to determine the applicability of the findings to other contexts (Ahmed, 2024). Ethical considerations Ethical approval was approved by the Ethics Committee of XXX (No: xxx). Participants were fully informed of the study’s purpose and procedures before the interview was conducted. Participants could refuse to participate or withdraw from the study as they were voluntarily interviewed in this study. Voice recording could also be stopped if the participants expressed their opposition. All participants’ personal information and expressed words are anonymized and securely stored to avoid accidental release. Results Participant’s demographic characteristics Table 2 presents the demographic characteristics of the 22 participants in this study. Among the participants, 45% (n = 10) were female and 55% (n = 12) were male, ranging in age from 60 to 79 years, with the mean age of 68 (SD = 5.2) years. The majority were married (82%, n = 18) and had one child (73%, n = 16). In terms of educational, 32% (n = 7) had completed primary education, 41% (n = 9) had a secondary school education, 18% (n = 4) had a high school education, and 9% (n = 2) had a college education. Regarding monthly income, 14% (n = 3) earned less than 2,000 RMB, 22% (n = 5) earned 2,000–3,000 RMB, 32% (n = 7) earned 3,001–4,000 RMB, 14% (n = 3) earned 4,001–5,000 RMB, 9% (n = 2) earned 5,001–6,000 RMB, and 9% (n = 2) earned over 6,000 RMB. For self-rated health status, 5% (n = 1) reported very poor, 27% (n = 6) poor, 41% (n = 9) good, 18% (n = 4) very good, and 9% (n = 2) excellent. In terms of religion, 18% (n = 4) were Buddhist, 14% (n = 3) followed other religions, and 68% (n = 15) reported no religious affiliation. Table 2 Demographic characteristics of participants ( N = 22). ID Age Gender Marital status Education level Religion Monthly income (RMB) Self-rated health status P 1 79 Female Married Primary school Buddhist 2,000–3,000 Poor P 2 69 Male Married High School Nil 4,001–5,000 Good P 3 63 Male Married Secondary school Nil 3,001–4,000 Very good P 4 63 Male Married Secondary school Others 3,001–4,000 Good P 5 60 Male Married High school Nil 5,001–6,000 Excellent P 6 62 Male Married College Nil >6,001 Very good P 7 68 Female Widowed Primary school Nil 6,001 Good P 9 66 Male Married Secondary school Nil 3,001–4,000 Good P 10 69 Male Married High school Nil 5,001–6,000 Poor P 11 64 Male Married Secondary school Nil 2,000–3,000 Very good P 12 66 Male Married Primary school Others <2,000 Good P 13 76 Female Widowed Primary school Nil 3,001–4,000 Very poor P 14 72 Female Married Primary school Nil 3,001–4,000 Good P 15 74 Female Married Primary school Buddhist <2,000 Poor P 16 67 Female Widowed High school Nil 4,001–5,000 Very good P 17 73 Male Married Secondary school Nil 3,001–4,000 Poor P 18 70 Male Married Primary school Buddhist 2,000–3,000 Good P 19 61 Female Married Secondary school Nil 3,001–4,000 Excellent P 20 67 Female Married Secondary school Nil 2,000–3,000 Good P 21 70 Female Married Secondary school Others 2,000–3,000 Good P 22 74 Male Married Secondary school Nil 4,001–5,000 Poor Themes and Subthemes The purpose of this study was to explore the factors that promote or hinder participation ACP among older adults. It employed a thematic analysis of semi-structured interview transcripts, resulting in four themes and eighteen subthemes, as shown in Table 3 . The four themes that emerged from the analysis were the perspective on death, drivers of ACP participation, barriers to ACP participation, and strategies for promoting ACP participation. Each theme was further categorised into subthemes. Table 3 Themes and subthemes of the study. Themes Subthemes Theme 1. Perspective on death 1.1 Calm about the outcome of death 1.2 Negative emotion about the process of dying 1.3 Perception of a good death Theme 2. Drivers of ACP participation 2.1 Reducing unnecessary suffering 2.2 Maintaining dignity 2.3 Ensuring autonomy in end-of-life decision-making 2.4 Reducing the financial and caregiving burden 2.5 Close family relationship 2.6 Positive attitudes among healthcare professionals Theme 3. Barriers to ACP participation 3.1 Lack of knowledge 3.2 Cultural influence 3.3 Lack of relevant legal and policies 3.4 The decisive role of family members 3.5 Negative attitudes of family members 3.6 Mistrust toward healthcare professionals Theme 4. Strategies to promote engagement in ACP 1.1 Optimal timing 1.2 Face-to-face with audio-visual aid 1.3 Inclusion of family members Theme 1: Perspective on death. Death and dying are part of the natural course of life. While death is the final outcome, the dying process can be brief or prolonged. Calm about the outcome of death Death was viewed as a natural and inevitable part of life. Many participants showed a rational and peaceful attitude toward death, viewing it as a natural law. “Oh man, death is nothing to fear. Everyone has to go through it—birth, aging, sickness, and finally death. That’s how life is. I’ve lived a long life already, and I think when the time comes, I’ll be ready to accept it calmly” (P 3) “Death is part of the natural cycle. There is life and there is death, don’t be sensitive, don’t be afraid.” (P 16) Negative emotion about the process of dying Rather than fearing death itself, participants expressed anxiety about the dying process, particularly the loss of autonomy, prolonged suffering, and dependence on others. “I’m not afraid of dying. What really scares me is being in a state where I can’t talk, can’t move, and need someone to feed and clean me. Er… I’ve sent some older adults away, and at that time of death, they can’t talk, they can’t express their emotions, but they shed tears, and this is emotionally hard ah…” (P 2) “If I could die in my sleep, that would be ideal. But what I dread is a prolonged process—being bedridden, relying on others for everything, suffering both physically and emotionally. That’s my greatest fear.” (P 8) Perception of a good death A “good death” was characterised by the absence of physical or psychological suffering as death nears, with a peaceful and painless dying process (Fan et al., 2019). Participants emphasized a strong desire for a good death. “I hope that when I die it will be easier, with less pain and less suffering. Er…if I had a very serious illness, I don’t want to be in the hospital, especially not in the ICU surrounded by beeping machines. I want to go at home, where I feel comfortable and at peace.” (P 8) “If I reach a point where there’s no hope. I just want to die straight and fast. Er…isn’t there euthanasia? I think that is just fine, I just want to be euthanised straight away.” (P 1) Theme 2: Drivers of ACP participation This refers to the benefits ACP offers older adults, close family relationship, and the positive attitudes of healthcare professionals toward ACP. Reducing unnecessary suffering Older adults identified ACP as a way to prevent unwanted medical interventions and ensure comfort in the final stages of life. Participants emphasized avoiding futile treatment when recovery was unlikely. “I want to avoid meaningless treatments. If my condition can’t be reversed, I don’t want doctors to keep me alive just for the sake of it. ACP lets me say no to suffering, and that’s important to me.” (P 7) “We’ve all seen it—people suffering on ventilators with no chance of recovery. I don’t want that. ACP helps ensure I won’t be put through that kind of torment if there’s no hope left.” (P 9) Maintaining dignity Maintaining dignity at the end-of-life was a key motivator for ACP engagement. Participants were determined to avoid dependence and indignity in their final moments. “I want to leave this world with some dignity. I don’t want to lie there, helpless, with tubes. I want to join ACP so I can leave this world with dignity and a clean body.” (P 2) “Er…I am a person of dignity, and I am willing to put myself out there through the ACP. I am determined not to drag myself around half dead with no quality of life or dignity.” (P 6) Ensuring autonomy in end-of-life decision-making Participants valued the sense of control ACP offered over their own life decisions. “Even if I say what I want now, my children may still disagree later. ACP is official. It ensures that my own voice matters, even if I can’t speak for myself.” (P19) “I feel calmer knowing I can decide my own end. Not leaving it to chance or to others. That gives me peace of mind, especially as I get older.” (P 22) Reducing the financial and caregiving burden Participants expressed concern about becoming a financial and caregiving burden to their families. ACP was viewed as a proactive step to alleviate these pressures. “Medical bills are so high, and I don’t want my children to suffer for me. They already have so much on their plates—jobs, families, loans. With ACP, I take that pressure off them.” (P 12) “When my time comes, I want it to be simple. No struggling to make decisions, no guilt for my kids. ACP helps ease that for them.” (P 15) Close family relationship Strong family connections facilitated effective communication on death, allowing older adults to express their personal end-of-life wishes freely. “My daughter and I are very close. We talk about everything—even my funeral. She knows my wishes, and it gives me comfort that she’ll honor them when the time comes.” (P 16) “ My wife and I have been classmates since elementary school, and we share a strong bond. My child is also very devoted. Our family is very close, and We’ve agreed on no life-sustaining treatments if I’m beyond recovery. That openness makes ACP easier. ” (P 17) Positive attitudes among healthcare professionals Encouragement and information from healthcare providers fostered openness to ACP. “Doctors and nurses need to explain ACP clearly. Many older people don’t even know it exists. If professionals guide us, we’d feel more confident and less scared of making the wrong decision.” (P 19) “When doctors show they care enough to talk about it, it means a lot. We feel respected. Death is an unknown experience, so we need their insights to help us understand and prepare for what lies ahead.” (P 22) Theme 3: Barriers to ACP participation Participants also highlighted several factors that hindered their involvement in ACP. Lack of knowledge Many participants acknowledged having a limited understanding of ACP, attributing this to insufficient access to information and education on ACP. “Erm…I’ve heard of it, but I don’t really know what it means. Is it like writing a will or saying no to treatment? I’ve only seen it in movies, not real life.” (P 2) “Some say it’s like choosing to die, like euthanasia. We need clear explanations, so we’re not confused.” (P 6) Cultural influence Culture profoundly influences attitudes toward illness, death and ACP, with traditional Chinese beliefs often posing barriers to open discussions about end-of-life care. “I don’t want to talk about it. Erm… it feels negative, pointless, and brings bad luck. I’d rather avoid the topic altogether than add to my mental burden.” (P 3) “I’m not interested in ACP and have no intention of participating. Discussing such matters with others feels inappropriate and unlucky. It only increases the psychological burden for the elderly.” (P 4) Filial piety and religious beliefs shaped resistance to ACP. “Personally, I’d want to join ACP. However, I’m concerned that this might clash with my children’s values and hinder their ability to fulfill their filial duties. Society would likely judge them negatively for it. So, I’m still uncertain.” (P 21) “My perspective may differ from others... I follow Buddhism. Making decisions about death feels like playing Bodhisattva. I worry that interfering may bring negative karma.” (P 8) Lack of relevant legal and policies The lack of enforceable laws and standardized ACP policies generated uncertainty about whether personal wishes would be honored. “Does our country have laws that protect the implementation of ACP? If it’s not backed by legal protections, then whether I participate or not doesn’t really matter.” (P 14) “I’m still a bit concerned about whether ACP is legally protected. Can it be guaranteed that my wishes will be honoured? What if something goes wrong in the process?” (P 9) The decisive role of family members Some participants placed full trust in their family members to make end-of-life decisions, rendering formal ACP plans unnecessary in their view. “Death is a deeply personal matter, and I would only entrust it to those I trust most. All I need to do is make sure my daughter understands my desires, and I’m sure she will carry them out as I ask.” (P 8) “Er…anyway, I’ve already shared my thoughts with my son. When the time comes, I’ll leave everything to him. Whatever decision he makes, I’ll accept it without question.” (P 12) Negative attitudes of family members Participants often avoided ACP due to emotional resistance from family members who were unwilling to engage in end-of-life conversations. “I once told my daughter I didn’t want to go to the hospital if I became seriously ill, but they shut me down, saying not to talk about such things while I’m healthy. I haven’t brought it up since.” (P 1) “I once mentioned to my wife what I would want to happen if I were to pass away, but she cried and couldn’t sleep after. She didn’t want to talk about it, so I dropped the subject.” (P 10) Mistrust toward healthcare professionals Mistrust toward healthcare professionals also discouraged older adults’ willingness to participate in ACP, as it directly impacts their belief that future medical care will align with their personal goals and preferences. “It may not make much sense to talk to doctors about death. Doctors see death all the time…it probably feels routine to them. If I share my fears, they might not take them seriously.” (P 2) “Doctors are trained to save lives. Even if I say I don’t want resuscitation, they might still try. I’m not sure they’d truly follow my wishes.” (P 8) Theme 4: Strategies for promoting ACP participation Participants suggested that optimal timing, face-to-face with audio-visual aid, and inclusion of family members could all be effective ways to encourage older adults to participate in ACP. Optimal timing Most participants agreed that ACP conversations should start early, when they are still healthy and cognitively capable of making clear decisions. “I believe it’s better to start early, while I’m still healthy and can approach it more rationally and objectively. That way, I’ll be more prepared if I become seriously ill later.” (P 18) “It’s best to have this conversation sooner rather than later. As I age, both my body and mind are deteriorating. Discussing it sooner helps me decide with a clear mind. If I wait until I’m very sick, I might not think properly.” (P 22) Face-to-face with audio-visual aid Direct interaction combined with visual aids was considered an effective approach for promoting understanding and comfort in discussing ACP. “ACP should be approached with care. It’s important to have a face-to-face conversation, and if the older person isn’t in the right frame of mind, it’s best to stop. Additionally, providing audiovisual materials with pictures also help older adults understand better.” (P 2) “I believe face-to-face communication is more personal. If something is unclear, we can address it immediately, which makes it easier to understand. But since doctors are busy, videos or picture-based pamphlets could help us learn too.” (P 11) Inclusion family members Engaging family members in ACP discussions was seen as essential for creating a supportive environment and reducing emotional discomfort for the older adult. “I believe the promotion of ACP shouldn’t focus solely on the elderly; it could feel harsh to them…It should involve families too. With their support, discussing ACP with doctors would feel less stressful.” (P 18) “ACP should be something not just for seniors, but for their family members too! I’d like to learn about it with my family so we can talk and decide together.” (P 20) Discussion This study offers valuable insights into the complex factors influencing participation ACP among older adults. By incorporating the perspectives, several key dimensions were identified that shape ACP participation. Similar qualitative research from countries such as the United States, Australia, England, Sweden, and the Netherlands has also underscored the importance of individual-level influences on ACP participation (Combes et al., 2021). However, our findings highlight the need for more comprehensive evidence to deepen understanding of the drivers and barriers affecting ACP participation, particularly in Chinese contexts. The theme of perspective of death revealed that the older adults held mixed views. Many regarded death itself as a natural and inevitable process, often with a sense of calm and acceptance, echoing prior research (Österlind et al., 2017). However, this study further found that participants expressed negative emotions when considering the dying process, particularly regarding pain and prolonged suffering, aligning with prior researches that highlighted the distinction between fears of dying versus death (Fleming et al., 2016; Tjernberg & Bökberg, 2020). This fear may stem from a lack of opportunities to discuss dying despite their interest in such conversations. Additionally, participants expressed the desire for a good death, characterised by a peaceful passing devoid of suffering (Fan et al., 2019). This aligns with broader cultural ideals (Tipwong et al., 2022) and underscores the potential role of ACP in mitigating death anxiety. The theme of drivers of ACP participation illustrates several motivating factors. Self-concern was a primary motivator, with participants seeking to reduce unnecessary suffering, maintain dignity and ensure autonomy in end-of-life decision-making. As populations age, safeguarding comfort and dignity at the end-of-life becomes increasingly vital (Hadley et al., 2017; Jin et al., 2022). Participants viewed ACP as a means to avoid painful and non-beneficial interventions in terminal conditions (KrakauerEric, 2024; Shaowei, 2021). In Chinese culture, dignity in death is highly valued (Li & Li, 2017). Participants felt ACP as a way to uphold this dignity and ensure that personal values were respected, consistent with both quantitative and qualitative findings (Lall et al., 2021; Yi et al., 2021). Older adults also valued ACP as a way to retain control over their healthcare decisions, ensuring that care aligned with their personal values, aligning with research showing a growing desire for autonomy in healthcare with age (Moilanen et al., 2021). Family-centered considerations also played a critical role. Participants noted that ACP could help alleviate the financial burden and caregiving pressure on families, particularly in the context of China’s one-child policy, where children face heavier economic and caregiving responsibilities (Cai & Feng, 2021). This aligns with the findings of a prior quantitative study (Gao et al., 2025). However, this study revealed that older adults with overly cohesive family ties might hesitate to engage in ACP, fearing that conversations about death would burden their loved ones emotionally. Additionally, some older adults tended to over-rely on family members to make decisions on their behalf, leading to their complete withdrawal from ACP discussions. Therefore, it is crucial to encourage family members to respect the autonomy of older adults and to foster an inclusive and supportive family environment that balances care with individual decision-making. The positive attitude among healthcare professionals toward ACP also emerged as critical. Participants appreciated guidance from trusted providers, which improved their understanding of medical options and the value of ACP. This finding aligns with studies suggesting that clinician-initiated discussions and ongoing provider engagement are crucial for successful ACP implementation (Cattagni Kleiner et al., 2019; Fleuren et al., 2021; Howard et al., 2018). The third theme elucidated key barriers that hinder older adults’ participation in ACP. A lack of knowledge of ACP was a predominant obstacle. This finding mirrors trends observed in other Asian countries, such as South Korea (Lee et al., 2018), China (Gao et al., 2025), Japan (Kawakami et al., 2021), and Singapore (Tang et al., 2023), where ACP is still relatively novel. As seen in previous studies, individuals’ understanding of ACP is crucial for their participation (Sung et al., 2019; Yi & Hohashi, 2018). Educating patients about their treatment choices and the implications of various end-of-life options not only helps shape their care preferences but also significantly increases the likelihood of ACP acceptance. Although prior quantitative research suggested that cultural factors were not associated with willingness to engage in ACP (Gao et al., 2025), the present study reveals cultural factors also influence older adults’ participating in ACP. While Western values of autonomy and open discussion, Confucian norms emphasize filial piety and avoid death-related conversations (Xu et al., 2023; Yang et al., 2021). In addition, religious beliefs, such as Buddhist views on natural death, may also reduce receptiveness to ACP (Tipwong et al., 2022; Upasen et al., 2022). These findings underscore the need to strengthen death education and foster a more scientific and open understanding of death. Lack of relevant legal and policies further constrain ACP uptake. Studies have demonstrated that legislative support positively influences ACP participation rates (Prince-Paul & DiFranco, 2017; Senda et al., 2018). According to Zhu. et al. (2020), China lacks national policies or standardized procedures, undermining trust and limiting implementation. In addition, some participants indicated that the decisive role of family members also deters ACP. Many participants preferred family members to make end-of-life choices, believing they would act in their best interest (Fan et al., 2019). This aligns with cultural norms in China, where familial authority often supersedes individual autonomy (Pei et al., 2021). A systematic review also noted that older adults may not want to participate in ACP if they are highly dependent on family members for decision-making (Musa et al., 2015). Additionally, the mistrust toward healthcare professionals also emerged as a significant barrier. Limited patient–provider interaction, inadequate follow-up care, and avoidance of death-related discussions contribute to this distrust (Howard et al., 2018; Tang et al., 2023). Notably, one study reported that only 5.9% of older adults had discussed ACP with their healthcare professionals (Cattagni Kleiner et al., 2019), and perceptions of healthcare professionals’ insensitivity or disregard for patient preferences further discourage engagement (van Dyck et al., 2021), underscoring the need for improved healthcare professionals training. Finally, the fourth theme addressed the strategies for promoting ACP participation. Participants emphasised the importance of optimal timing, identifying it as the ideal moment to initiate discussions about end-of-life care (Chi et al., 2018). Many preferred to address ACP as early as possible, ideally before cognitive or psychological decline, consistent with previous research showing that early engagement facilitates better planning outcomes (Chi et al., 2018). Preferences for face-to-face discussions supplemented with audio-visual aids was frequently cited. While traditional formats rely on verbal or written materials (Kavalieratos et al., 2015), integrating integrating audio-visual aids can improve comprehension and personalize decision-making (Hendricks Sloan et al., 2016). Given the deeply personal nature of ACP, which reflects individual beliefs and experiences, face-to-face communication is the most effective approach (Kavalieratos et al., 2015). These methods are especially helpful for older adults facing physical or digital challenges. The involvement of family members was considered essential. In Chinese culture, where end-of-life decisions are typically made collectively, family support is vital to ACP participation (Michael et al., 2017; Wang et al., 2022). Educating family members can help normalize ACP discussions, reduce stigma, and foster a supportive environment for older adults to express their preferences more openly. Strengths and Limitations The strengths of this study are purposive sampling and methodological triangulation. Purposive sampling allowed for the selection of participants with diverse demographic backgrounds, ensuring a heterogeneous sample of older adults residing in community settings in China. Triangulation further enhanced the study’s credibility. Two independent observers reviewed the study design, interview procedures, and thematic analysis. This helped to avoid personal bias and promoted self-reflection throughout the research process, enabling researchers to gain comprehensive insights. Limitations include the fact that most interview participants were in relatively good health, which may have introduced bias and limited the transferability of the findings. Future research should include participants with a broader range of health conditions to capture more diverse and representative perspectives. Conclusions The results of this study contribute to a deeper understanding of drivers and barriers to ACP participation among community-dwelling older adults in China. It highlights the importance of strengthening death education and engaging family members in supporting the ACP process. By recognizing the multifaceted factors that influence participation in ACP, targeted interventions can be developed to encourage engagement among older adults and advance the implementation of ACP in China. Declarations Ethics approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Sichuan Provincial People’s Hospital (Approval ID: 20240421). Informed consent was obtained from all participants included in the study which was a completely voluntary, anonymous, and unrewarded study. Clinical trial number Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets generated during and/or analysed during the current study will be shared only on request with the approval from the Universiti Malaya thesis Unit. Plesease contacted corresponding author if needed. Competing interests The authors declare that they have no competing interests. Funding This research was supported by the Chengdu Municipal Health Commission (2024442) and the Scientific Research Project of Sichuan Cadre Health Committee (2023-225). Authors' contributions FG: Conceptualization, Methodology, Data Collation, Formal Analysis, Role/Writing - Original Manuscript, Project Administration KW: Conceptualization, Methodology, Formal Analysis, Resources. LX: Conceptualization, Methodology, Original Manuscript, Resources. CCC: Conceptualization, Supervision. RH: Conceptualization, Methodology, Original Manuscript, Resources. CPL and MFL: Supervision and Writing - Review. All authors: Validation, Writing - Review and Editing. References Ahmed, S. K. (2024). The pillars of trustworthiness in qualitative research. Journal of Medicine, Surgery, and Public Health , 2 , 100051. Cai, Y., & Feng, W. (2021). The social and sociological consequences of China's one-child policy. Annual review of sociology , 47 (1), 587–606. Cattagni Kleiner, Anne Santos-Eggimann, Brigitte Fustinoni, Sarah Dürst, Anne-Véronique Haunreiter, Katja Rubli-Truchard, & Seematter-Bagnoud, E. (2019). Advance care planning dispositions: the relationship between knowledge and perception. BMC geriatrics , 19 , 1–11. Chi, H.-L., Cataldo, J., Ho, E. Y., & Rehm, R. S. (2018). Can we talk about it now? Recognizing the optimal time to initiate end-of-life care discussions with older Chinese Americans and their families. Journal of transcultural nursing , 29 (6), 532–539. Combes, S., Gillett, K., Norton, C., & Nicholson, C. J. (2021). The importance of living well now and relationships: a qualitative study of the barriers and enablers to engaging frail elders with advance care planning. Palliative medicine , 35 (6), 1137–1147. Daniel, B. K. (2019). Student experience of the maximum variation framework for determining sample size in qualitative research. 18th European conference on research methodology for business and management studies, Eryılmaz, Ö. (2022). Are dissertations trustworthy enough? The case of Turkish ph. d. dissertations on social studies education. Participatory Educational Research , 9 (3), 344–361. Fan, S. Y., Sung, H. C., & Wang, S. C. (2019). The experience of advance care planning discussion among older residents in a long-term care institution: A qualitative study. Journal of Clinical Nursing , 28 (19–20), 3451–3458. Fleming, J., Farquhar, M., Collaboration, C. C. o.-s. C. S., Brayne, C., & Barclay, S. (2016). Death and the oldest old: attitudes and preferences for end-of-life care-qualitative research within a population-based cohort study. Plos one , 11 (4), e0150686. Fleuren, N., Depla, M. F., Pasman, H. R. W., Janssen, D. J., Onwuteaka-Philipsen, B. D., Hertogh, C. M., & Huisman, M. (2021). Association between subjective remaining life expectancy and advance care planning in older adults: a cross-sectional study. Journal of pain and symptom management , 62 (4), 757–767. Gao, F., Chui, P. L., Che, C. C., & Wang, K. (2025). The mediating role of family cohesion in the relationship between death anxiety and readiness toward advance care planning among Chinese community-dwelling older adults: A cross-sectional study. Geriatric Nursing , 61 , 192–199. Gao, F., Chui, P. L., Che, C. C., Xiao, L., & Zhang, Q. (2024). Advance care planning readiness among community-dwelling older adults and the influencing factors: a scoping review. BMC Palliative Care , 23 (1), 255. Gibbs, G. (2007). Thematic Coding and Categorizing. In (pp. 38–56): Analyzing qualitative data,. Hadley, E. C., Kuchel, G. A., Newman, A. B., Allore, H. G., Bartley, J. M., Bergeman, C. S., Blinov, M. L., Colon-Emeric, C. S., Dabhar, F. S., & Dugan, L. L. (2017). Report: NIA workshop on measures of physiologic resiliencies in human aging. The Journals of Gerontology: Series A , 72 (7), 980–990. Han, S., Li, H., & Xia, L. (2018). Implementation and research progress of Advance Care Planning: a review. Chinese Nursing Management , 18 (3), 298–302. Hendricks Sloan, D., Peters, T., Johnson, K. S., Bowie, J. V., Ting, Y., & Aslakson, R. (2016). Church-based health promotion focused on advance care planning and end-of-life care at Black Baptist churches: a cross-sectional survey. Journal of Palliative Medicine , 19 (2), 190–194. Howard, M., Bernard, C., Klein, D., Tan, A., Slaven, M., Barwich, D., You, J. J., Asselin, G., Simon, J., & Heyland, D. K. (2018). Older patient engagement in advance care planning in Canadian primary care practices: Results of a multisite survey. Can Fam Physician , 64 (5), 371–377. Hu, J.-b., Zhou, W.-h., Hu, S.-h., Huang, M.-l., Wei, N., Qi, H.-l., Huang, J.-w., & Xu, Y. (2013). Cross-cultural difference and validation of the Chinese version of Montreal Cognitive Assessment in older adults residing in Eastern China: preliminary findings. Archives of Gerontology and Geriatrics , 56 (1), 38–43. Jin, S., Liu, S., Li, J., Ning, X., & Liu, X. (2022). Stumbling and Growing: A Bibliometric Study of Academic Publications of Palliative Care in Mainland China for 2010–2020. Journal of Palliative Care , 08258597211039056. Kavalieratos, D., Ernecoff, N. C., Keim-Malpass, J., & Degenholtz, H. B. (2015). Knowledge, attitudes, and preferences of healthy young adults regarding advance care planning: a focus group study of university students in Pittsburgh, USA. BMC Public Health , 15 , 1–7. Kawakami, A., Kwong, E. W., Lai, C. K., Song, M. S., Boo, S., & Yamamoto-Mitani, N. (2021). Advance care planning and advance directive awareness among East Asian older adults: Japan, Hong Kong and South Korea. Geriatrics & gerontology international , 21 (1), 71–76. Kelley, A. S., & Morrison, R. S. (2015). Palliative care for the seriously ill. New England Journal of Medicine , 373 (8), 747–755. Khokhar, S., Pathan, H., Raheem, A., & Abbasi, A. M. (2020). Theory development in thematic analysis: Procedure and practice. Review of Applied Management and Social Sciences , 3 (3), 423–433. Krakauer, E. L. (2024). How to Respond Responsibly to Suffering of Others? Rethinking Palliative Care for China. Medical Journal of Peking Union Medical College Hospital , 15 (1), 7–11. KrakauerEric, L. (2024). How to Responsibly Respond to Others' Suffering? — Rethinking Palliative Care in China. Medical Journal of Peking Union Medical College Hospital , 15 (1), 7–11. Lall, P., Dutta, O., Tan, W. S., Patinadan, P. V., Kang, N. Q., Low, C. K., Car, J., & Ho, A. H. Y. (2021). “I decide myself”-A qualitative exploration of end of life decision making processes of patients and caregivers through Advance Care Planning. Plos one , 16 (6), e0252598. Lee, J. E., Shin, D. W., Son, K. Y., Park, H. J., Lim, J.-Y., Song, M. S., Park, Y.-H., & Cho, B. (2018). Factors influencing attitudes toward advance directives in Korean older adults. Archives of Gerontology and Geriatrics , 74 , 155–161. Li, Y., & Li, J. (2017). Death with dignity from the Confucian perspective. Theoretical Medicine and Bioethics , 38 , 63–81. Liao, J., Wu, B., Ni, P., & Mao, J. (2019). Advance directive preferences among terminally ill older patients and its facilitators and barriers in China: a scoping review. Journal of the American Medical Directors Association , 20 (11), 1356–1361. e1352. Michael, N., O’Callaghan, C., & Sayers, E. (2017). Managing ‘shades of grey’: a focus group study exploring community-dwellers’ views on advance care planning in older people. BMC Palliative Care , 16 , 1–9. Moilanen, T., Kangasniemi, M., Papinaho, O., Mynttinen, M., Siipi, H., Suominen, S., & Suhonen, R. (2021). Older people’s perceived autonomy in residential care: An integrative review. Nursing ethics , 28 (3), 414–434. Munhall, P. (2012). Nursing research . Jones & Bartlett Learning. Musa, I., Seymour, J., Narayanasamy, M. J., Wada, T., & Conroy, S. (2015). A survey of older peoples’ attitudes towards advance care planning. Age and ageing , 44 (3), 371–376. Nedjat-Haiem, F. R., Carrion, I. V., Gonzalez, K., Bennett, E. D., Ell, K., O’Connell, M., Thompson, B., & Mishra, S. I. (2018). Exploring motivational interviewing to engage Latinos in advance care planning: a community-based social work intervention. American Journal of Hospice and Palliative Medicine® , 35 (8), 1091–1098. Organization, W. H. (2025). Ageing and health in China . Österlind, J., Ternestedt, B. M., Hansebo, G., & Hellström, I. (2017). Feeling lonely in an unfamiliar place: older people’s experiences of life close to death in a nursing home. International Journal of Older People Nursing , 12 (1), e12129. Pei, Y., Zhang, W., & Wu, B. (2021). Advance care planning engagement and end-of-life preference among older Chinese Americans: do family relationships and immigrant status matter? Journal of the American Medical Directors Association , 22 (2), 340–343. Prince-Paul, M., & DiFranco, E. (2017). Upstreaming and normalizing advance care planning conversations—a public health approach. Behavioral sciences , 7 (2), 18. Senda, K., Nishikawa, M., Miura, H., & Arai, H. (2018). There is something about advance care planning: Report on Dr Karen Detering's lecture on advance care planning at the Annual Meeting of the Japan Geriatrics Society, 2018. Geriatrics & gerontology international , 18 (12). Shaowei, W. Y. X. H. L. (2021). A comparison of end-of-life care preferences between nursing home residents and community-dwellers. China Journal Nursing , April 2021, Vol. 56, No. 4 , 567–573. Shen, X., Zhou, S., & Zhang, X. (2022). Services for Aging Persons in China . https://doi.org/10.1007/978-3-030-98032-0 (Global Perspectives on Health Geography) Sudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Matlock, D. D., Rietjens, J. A., Korfage, I. J., & Ritchie, C. S. (2017). Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. Journal of pain and symptom management , 53 (5), 821–832. e821. Sung, H.-C., Wang, S.-C., Fan, S.-Y., & Lin, C.-Y. (2019). Advance care planning program and the knowledge and attitude concerning palliative care. Clinical Gerontologist , 42 (3), 238–246. Tang, J. M. S., Cher, B. X. B. B., Lim, S. F., & Siah, C. J. R. (2023). A meta-synthesis on the older adults' perspective of advance care planning. Journal of Clinical Nursing , 32 (13–14), 4176–4194. Tipwong, A., Ruamsook, T., Hongkittiyanon, T., & Kgowsiri, K. (2022). The perceptions on good death of the older adults in the semi-urban community: A qualitative study. International Journal of Nursing Sciences , 9 (3), 389–396. Tjernberg, J., & Bökberg, C. (2020). Older persons’ thoughts about death and dying and their experiences of care in end-of-life: a qualitative study. BMC nursing , 19 , 1–10. Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care , 19 (6), 349–357. Upasen, R., Thanasilp, S., Akkayagorn, L., Chimluang, J., Tantitrakul, W., Doutrich, D. L., & Saengpanya, W. (2022). Death acceptance process in Thai Buddhist patients with life-limiting cancer: A grounded theory. Global Qualitative Nursing Research , 9 , 23333936221111809. van Dyck, L. I., Paiva, A., Redding, C. A., & Fried, T. R. (2021). Understanding the role of knowledge in advance care planning engagement. Journal of pain and symptom management , 62 (4), 778–784. Wang, K., Sun, F., Liu, Y., Kong, D., & De Fries, C. M. (2022). Attitude toward family involvement in end-of-life care among older Chinese Americans: how do family relationships matter? Journal of Applied Gerontology , 41 (2), 380–390. Xu, X., Chau, P. H., Cheung, D. S. T., Ho, M. H., & Lin, C. C. (2023). Preferences for end-of‐life care: A cross‐sectional survey of Chinese frail nursing home residents. Journal of Clinical Nursing , 32 (7–8), 1455–1465. Yang, Z., Hou, B., Chen, P., & Zhang, H. (2021). Preference and influencing factors of advance care planning for Chinese elderly patients with chronic diseases: a mixed-methods approach. Journal of Hospice & Palliative Nursing , 23 (2), 178–186. Yi, Q., & Hohashi, N. (2018). Comparison of perceptions of domestic elder abuse among healthcare workers based on the Knowledge-Attitude-Behavior (KAB) model. Plos one , 13 (11), e0206640. Yi, Y. C., Nu, L. C., Cheng, Y. C., Fei, T. Z., Rong, H. Y., Min, S. F., Chiao, H. F., & Jen, L. C. (2021). Insisting on Life Dignity: Advance Care Planning in Taiwan During COVID-19 Pandemic. Zhu, T., Zhang, J., Shi, Y., Yi, J., Zhang, Q., Zhao, Y., Gao, Q., Wang, Z., Li, J., & Liu, X. (2020). Awareness and attitudes toward advance care planning among community-dwelling older adults in China: a mixed-methods study. American Journal of Hospice and Palliative Medicine® , 37 (9), 743–749. Zhu., Zhang, J., Shi, Y., Yi, J., Zhang, Q., Zhao, Y., Gao, Q., Wang, Z., Li, J., Liu, X., & Liu, D. (2020). Awareness and Attitudes Toward Advance Care Planning Among Community-Dwelling Older Adults in China: A Mixed-Methods Study. Am J Hosp Palliat Care , 37 (9), 743–749. https://doi.org/10.1177/1049909120905255 Additional Declarations No competing interests reported. Supplementary Files COREQChecklist.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 26 Sep, 2025 Editor assigned by journal 23 Sep, 2025 Editor invited by journal 04 Sep, 2025 Submission checks completed at journal 03 Sep, 2025 First submitted to journal 03 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7425642","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":525644325,"identity":"853d6530-cfa0-4467-a1d1-b4aa1c2083a9","order_by":0,"name":"Fang Gao","email":"","orcid":"","institution":"Sichuan Academy of Medical Sciences \u0026 Sichuan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fang","middleName":"","lastName":"Gao","suffix":""},{"id":525644326,"identity":"9ec2a254-aa41-4df2-b899-53be0a24852f","order_by":1,"name":"Kun Wang","email":"","orcid":"","institution":"Qionglai Medical Center Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Wang","suffix":""},{"id":525644327,"identity":"366f7d49-d8ad-404c-b9e6-746b87306ffd","order_by":2,"name":"Li Xiao","email":"","orcid":"","institution":"Sichuan Academy of Medical Sciences \u0026 Sichuan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Xiao","suffix":""},{"id":525644328,"identity":"d77bd838-f790-4615-974f-85311c2e3fbc","order_by":3,"name":"Chong Chin Che","email":"","orcid":"","institution":"Universiti Malaya","correspondingAuthor":false,"prefix":"","firstName":"Chong","middleName":"Chin","lastName":"Che","suffix":""},{"id":525644331,"identity":"a378ad24-27bd-4483-8879-fb8af8a41431","order_by":4,"name":"Rong Hu","email":"","orcid":"","institution":"Sichuan Academy of Medical Sciences \u0026 Sichuan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rong","middleName":"","lastName":"Hu","suffix":""},{"id":525644336,"identity":"ddcaf419-6800-4130-9d38-3c00a6920e49","order_by":5,"name":"Ping Lei Chui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACCQaGAwwGDAx8DIyND8AiB4jVwsbA2GxAtBYwYAMiCaK08M/uMTxcUHDHro29ua2aN4dBju9GAutmHnyW3DljcHiGwbPkNp6Dbbd5tzEYS95IYLuNT4uBRI7BYR6Dw8lsEolgLYkbiNci/7CtGKilnmgtdmwSjG3MQC0JBoS0SNxIKwD65XACG09is+TcbRKGM888bLs5B48W/hnJmz8X/Dlsz89+/OGHt9ts5PmOJx+78QaPFhBgBuLEBqitQMzYwITPYTAt9igijD8IaBkFo2AUjIIRBQBGPk7wWIxHFQAAAABJRU5ErkJggg==","orcid":"","institution":"Universiti Malaya","correspondingAuthor":true,"prefix":"","firstName":"Ping","middleName":"Lei","lastName":"Chui","suffix":""},{"id":525644337,"identity":"0035681c-602f-4a8c-bcee-2e0288c52a3d","order_by":6,"name":"Ming Fei Li","email":"","orcid":"","institution":"Sichuan Academy of Medical Sciences \u0026 Sichuan Provincial People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"Fei","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-08-21 11:23:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7425642/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7425642/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92997204,"identity":"a1f21e4c-8035-4529-8e9f-33f1cd19fa3b","added_by":"auto","created_at":"2025-10-08 03:49:20","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101392,"visible":true,"origin":"","legend":"","description":"","filename":"DriversandbarrierstoparticipateinadvancecareplanninginsightsfromChinesecommunitydwellingolderadult.docx","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/41ce395e8d2d456323f518a3.docx"},{"id":92997205,"identity":"6e302caa-0ee0-4a47-8e3b-872e0cca770e","added_by":"auto","created_at":"2025-10-08 03:49:20","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8129,"visible":true,"origin":"","legend":"","description":"","filename":"6e709fec262e456aa56aad5701df6d1a.json","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/35129cb2af5158d115c6071c.json"},{"id":92997208,"identity":"c37e1ba7-08ce-4d85-8104-47e55e963b8a","added_by":"auto","created_at":"2025-10-08 03:49:20","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":882417,"visible":true,"origin":"","legend":"","description":"","filename":"COREQChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/6b2dbae7532ec58e9f3c5836.pdf"},{"id":92997826,"identity":"5798ae6d-1745-4237-8f31-d47a583c8c92","added_by":"auto","created_at":"2025-10-08 03:57:20","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97189,"visible":true,"origin":"","legend":"","description":"","filename":"6e709fec262e456aa56aad5701df6d1a1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/6e3624961f82524176bf829a.xml"},{"id":92997209,"identity":"b2568c9c-ba89-4689-8e4d-721b0ca59c6c","added_by":"auto","created_at":"2025-10-08 03:49:20","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91250,"visible":true,"origin":"","legend":"","description":"","filename":"6e709fec262e456aa56aad5701df6d1a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/27d81dbb58d50bf307518241.xml"},{"id":92997828,"identity":"df5b41ea-4d96-4034-b49a-d5eb7a30e96a","added_by":"auto","created_at":"2025-10-08 03:57:21","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":107437,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/7ac3b51f2946ecf97117545c.html"},{"id":92997937,"identity":"abd1dc44-1687-489f-a512-1f6eefd940a9","added_by":"auto","created_at":"2025-10-08 04:05:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1208574,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/b1adf3ed-27b5-4653-8ce5-cb308ba692ae.pdf"},{"id":92997206,"identity":"d8ca3e51-0a59-4f3a-820a-c501f4317642","added_by":"auto","created_at":"2025-10-08 03:49:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":882417,"visible":true,"origin":"","legend":"","description":"","filename":"COREQChecklist.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7425642/v1/0413afd93eb66673b1de1d36.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Drivers and barriers to participate in advance care planning: insights from Chinese community-dwelling older adults","fulltext":[{"header":"Background","content":"\u003cp\u003eChina has become the largest country with an aging population due to its large population base and low birth rate (Shen et al., 2022). The proportion of people aged 60 and over is expected to increase to 28% (402\u0026nbsp;million) by 2040 (Organization, 2025). However, the development of end-of-life care has not kept pace with this demographic shift. Deep-rooted cultural taboos surrounding death, underdeveloped legal frameworks, and insufficient institutional support in clinical and community settings continue to impede open conversations about end-of-life medical decisions (Liao et al., 2019). Consequently, many older adults are suffering from excessive or unnecessary medical treatment that is not in line with their wishes (Krakauer, 2024). This not only leads to the inefficient use of medical resources but also imposes significant physical, psychological and economic burdens on both the older adult in question and their families. As humanistic values gain traction and awareness of individual autonomy grows, ensuring dignity and comfort in dying has become a key aspect of successful aging (Jin et al., 2022).\u003c/p\u003e\u003cp\u003eAdvance care planning (ACP) is the process by which individuals make decisions about their preferences for medical care, including consenting to, refusing, or discontinuing treatment, as well as appointing a surrogate decision-maker (Sudore et al., 2017). ACP has been recognised as an essential aspect of patient-centred and cost-effective end-of-life care (Kelley \u0026amp; Morrison, 2015) and has been widely implemented in many Western countries (Nedjat-Haiem et al., 2018). In contrast, ACP remains relatively unfamiliar in mainland China. A survey in Zhengzhou found that 92.7% of older adults had never heard of ACP (Zhu et al., 2020). Studies in China have primarily focused on patients with advanced cancer, addressing only treatment preferences and attitudes toward death (Han et al., 2018). This narrow focus limits the representativeness of the study findings to the broader community population and neglects the perspectives of community-dwelling older adults, the primary target group for developing ACP.\u003c/p\u003e\u003cp\u003eConsidering that ACP is a deeply personal and subjective issue, shaped by individual values, beliefs and experiences (Munhall, 2012), integrating the voices of older adults is crucial. Recent evidence suggests that their willingness to engage in ACP is influenced by personal, relational, professional, and policy-related factors (Gao et al., 2024). Capturing these perspectives can enrich our understanding of the drivers and barriers to ACP participation and inform more culturally sensitive practices. Therefore, this study aimed to explore the factors that promote or hinder participating in ACP from the perspectives of Chinese community-dwelling older adults. The research questions were as follows (i) What are the factors that promote community-dwelling older adults' participation in ACP? (ii) What are the factors that hinder community-dwelling older adults' participation in ACP?\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign and setting\u003c/h2\u003e\u003cp\u003eThis study employed a descriptive, qualitative approach using individual face-to-face semi-structured interviews to explore drivers and barriers to participate in ACP. The research was carried out in four community health service centers in Chengdu city. The study was presented according to the Consolidated Criteria for reporting Qualitative Research checklist (Tong et al., 2007) (Appendix 1).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eA purposive sampling method (Daniel, 2019) was used to recruit older adults from community health service centers in Chengdu city. These participants had previously consented and taken part in a survey on readiness toward ACP (Gao et al., 2025) and agreed to share their insights for this study. The inclusion criteria for participation were as follows: aged 60 years or older; a result of the montreal cognitive assessment\u0026thinsp;\u0026ge;\u0026thinsp;26 (Hu et al., 2013), assessed by trained researchers. The sample size of the qualitative study is determined by data saturation, and no new information emerges from the data collection process. A total of 22 participants were interviewed individually to obtain their perspectives on the factors that promote or hinder participating in ACP.\u003c/p\u003e\n\u003ch3\u003eResearch team characteristics\u003c/h3\u003e\n\u003cp\u003eThe research team was exclusively female and consisted of four nurses (GF, WK, XL, and HR), and two nursing lecturers (CPL and CCC). GF was a PhD candidate at XX University, WK, XL and HR were masters, all specialize in nursing and gerontology and have qualitative research training and experience in doing qualitative research. The two team members (CPL and CCC) hold a PhD qualification and have expertise in qualitative research. None of the members of the research team had prior relationship with the respondents.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were collected from April 2 to July 2024 using semi-structured, in-depth interviews. All interviews were conducted in Mandarin by GF in a private, quiet room within selected community health service centers at a time convenient for the participants. WK and XL served as observers and were responsible for taking field notes. Each interview lasted approximately 30 to 45 minutes and was audio-recorded with participants\u0026rsquo; consent. Notably, no participants dropped out during the interview process, and no repeat interviews carried out. Data collection continued until data saturation was reached. All audio recordings were transcribed verbatim immediately following each interview.\u003c/p\u003e\u003cp\u003eThe interviews aimed to explore the drivers and barriers of participating3 in ACP among older adults. Demographic information was collected, including age, gender, marital status, education level, religion, monthly income, and self-rated health status. The interview guide was developed by the authors (GF, WK XL, and HR) based on the relevant literature and the study objective was reviewed by CPL and CCC. Two pilot interviews were conducted with older adults who were not included in the final analysis to refine the interview questions and identify any issues. After minor revisions, the finalized interview guide is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInterview guide.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e(1) How do you view death?\u003c/p\u003e\u003cp\u003e(2) What kind of end-of-life care do you want?\u003c/p\u003e\u003cp\u003e(3) How do you think about ACP?\u003c/p\u003e\u003cp\u003e(4) Are you willing to participate in ACP?\u003c/p\u003e\u003cp\u003e(5) What approach you like to proceed with the ACP?\u003c/p\u003e\u003cp\u003e(6) What are your suggestions for promoting ACP in China?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eData processing \u0026 analysis\u003c/h3\u003e\n\u003cp\u003eIn this study, all audio-recorded interviews were transcribed verbatim in Chinese within 24 hours of the interviews. Transcriptions were manually completed by the primary researcher (GF), ensuring close engagement with the data. The data were coded by GF and WK independently for each participant in Chinese to retain cultural and linguistic nuances. key quotations were then translated into English using a forward and back-translation process. The initial translation was done by GF, a bilingual researcher trained in qualitative methods, followed by an independent back-translation by CPL, another bilingual translator. Discrepancies were resolved through discussion to ensure conceptual equivalence between the original and translated texts.\u003c/p\u003e\u003cp\u003eThe data collected were analysed using thematic analysis (Khokhar et al., 2020) in NVIVO 14, following Gibbs (2007) six-step approach. The analysis began with familiarization and initial coding, after which the coded transcripts were compared with the original recordings to ensure accuracy. Transcripts were then returned to participants for member checking; no corrections or comments were received. In the subsequent steps, potential themes were identified, reviewed, and refined through multiple rounds of discussion to ensure clarity, consistency, and representativeness. The final stages involved defining and naming the themes and presenting the findings thematically. This structured and rigorous analytical approach provided an in-depth understanding of the drivers and barriers influencing older adults\u0026rsquo; participation in ACP, thereby strengthening the trustworthiness and reliability of the results.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eRigor and trustworthiness\u003c/h2\u003e\u003cp\u003eThe trustworthiness of the study was evaluated using four key criteria: credibility, dependability, confirmability, and transferability (Ahmed, 2024). Credibility was strengthened through triangulation. Two independent observers (XL and HR), who did not involvement in data collection, contributed field notes and reviewed the study design, interview procedures, and thematic analysis. The integration of both interview data and observational field notes enabled triangulation, which enriched the interpretation of findings and reduced the risk of bias associated with reliance on a single data source (Ahmed, 2024). Dependability was ensured by maintaining a detailed audit trail documenting all methodological decisions, modifications, and justifications throughout the research process. Furthermore, the research team was divided into two subgroups that independently analysed and compared the data, thereby reinforcing the consistency and reliability of the results (Eryılmaz, 2022). Confirmability was enhanced through member checking, whereby key points from each interview were summarized during and after the session and verified by participants. This allowed respondents to affirm or clarify the researchers\u0026rsquo; interpretations, promoting greater objectivity (Ahmed, 2024). Finally, transferability was supported through the use of thick description, providing rich contextual details about the participants and research setting. This approach allows readers to determine the applicability of the findings to other contexts (Ahmed, 2024).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eEthical approval was approved by the Ethics Committee of XXX (No: xxx). Participants were fully informed of the study\u0026rsquo;s purpose and procedures before the interview was conducted. Participants could refuse to participate or withdraw from the study as they were voluntarily interviewed in this study. Voice recording could also be stopped if the participants expressed their opposition. All participants\u0026rsquo; personal information and expressed words are anonymized and securely stored to avoid accidental release.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eParticipant\u0026rsquo;s demographic characteristics\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the demographic characteristics of the 22 participants in this study. Among the participants, 45% (n\u0026thinsp;=\u0026thinsp;10) were female and 55% (n\u0026thinsp;=\u0026thinsp;12) were male, ranging in age from 60 to 79 years, with the mean age of 68 (SD\u0026thinsp;=\u0026thinsp;5.2) years. The majority were married (82%, n\u0026thinsp;=\u0026thinsp;18) and had one child (73%, n\u0026thinsp;=\u0026thinsp;16). In terms of educational, 32% (n\u0026thinsp;=\u0026thinsp;7) had completed primary education, 41% (n\u0026thinsp;=\u0026thinsp;9) had a secondary school education, 18% (n\u0026thinsp;=\u0026thinsp;4) had a high school education, and 9% (n\u0026thinsp;=\u0026thinsp;2) had a college education. Regarding monthly income, 14% (n\u0026thinsp;=\u0026thinsp;3) earned less than 2,000 RMB, 22% (n\u0026thinsp;=\u0026thinsp;5) earned 2,000\u0026ndash;3,000 RMB, 32% (n\u0026thinsp;=\u0026thinsp;7) earned 3,001\u0026ndash;4,000 RMB, 14% (n\u0026thinsp;=\u0026thinsp;3) earned 4,001\u0026ndash;5,000 RMB, 9% (n\u0026thinsp;=\u0026thinsp;2) earned 5,001\u0026ndash;6,000 RMB, and 9% (n\u0026thinsp;=\u0026thinsp;2) earned over 6,000 RMB. For self-rated health status, 5% (n\u0026thinsp;=\u0026thinsp;1) reported very poor, 27% (n\u0026thinsp;=\u0026thinsp;6) poor, 41% (n\u0026thinsp;=\u0026thinsp;9) good, 18% (n\u0026thinsp;=\u0026thinsp;4) very good, and 9% (n\u0026thinsp;=\u0026thinsp;2) excellent. In terms of religion, 18% (n\u0026thinsp;=\u0026thinsp;4) were Buddhist, 14% (n\u0026thinsp;=\u0026thinsp;3) followed other religions, and 68% (n\u0026thinsp;=\u0026thinsp;15) reported no religious affiliation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic characteristics of participants (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarital\u003c/p\u003e\u003cp\u003estatus\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMonthly income (RMB)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSelf-rated health status\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBuddhist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2,000\u0026ndash;3,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh School\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4,001\u0026ndash;5,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5,001\u0026ndash;6,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026gt;6,001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;2,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDivorced\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCollege\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBuddhist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026gt;6,001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5,001\u0026ndash;6,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2,000\u0026ndash;3,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;2,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eVery poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBuddhist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;2,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4,001\u0026ndash;5,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eVery good\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eBuddhist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2,000\u0026ndash;3,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3,001\u0026ndash;4,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eExcellent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2,000\u0026ndash;3,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2,000\u0026ndash;3,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP 22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSecondary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNil\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4,001\u0026ndash;5,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003ePoor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eThemes and Subthemes\u003c/h2\u003e\u003cp\u003eThe purpose of this study was to explore the factors that promote or hinder participation ACP among older adults. It employed a thematic analysis of semi-structured interview transcripts, resulting in four themes and eighteen subthemes, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The four themes that emerged from the analysis were the perspective on death, drivers of ACP participation, barriers to ACP participation, and strategies for promoting ACP participation. Each theme was further categorised into subthemes.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and subthemes of the study.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSubthemes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 1. Perspective on death\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1.1 Calm about the outcome of death\u003c/p\u003e\u003cp\u003e1.2 Negative emotion about the process of dying\u003c/p\u003e\u003cp\u003e1.3 Perception of a good death\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 2. Drivers of ACP participation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e2.1 Reducing unnecessary suffering\u003c/p\u003e\u003cp\u003e2.2 Maintaining dignity\u003c/p\u003e\u003cp\u003e2.3 Ensuring autonomy in end-of-life decision-making\u003c/p\u003e\u003cp\u003e2.4 Reducing the financial and caregiving burden\u003c/p\u003e\u003cp\u003e2.5 Close family relationship\u003c/p\u003e\u003cp\u003e2.6 Positive attitudes among healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 3. Barriers to ACP participation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1 Lack of knowledge\u003c/p\u003e\u003cp\u003e3.2 Cultural influence\u003c/p\u003e\u003cp\u003e3.3 Lack of relevant legal and policies\u003c/p\u003e\u003cp\u003e3.4 The decisive role of family members\u003c/p\u003e\u003cp\u003e3.5 Negative attitudes of family members\u003c/p\u003e\u003cp\u003e3.6 Mistrust toward healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme 4. Strategies to promote engagement in ACP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.1 Optimal timing\u003c/p\u003e\u003cp\u003e1.2 Face-to-face with audio-visual aid\u003c/p\u003e\u003cp\u003e1.3 Inclusion of family members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eTheme 1: Perspective on death.\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDeath and dying are part of the natural course of life. While death is the final outcome, the dying process can be brief or prolonged.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCalm about the outcome of death\u003c/h2\u003e\u003cp\u003eDeath was viewed as a natural and inevitable part of life. Many participants showed a rational and peaceful attitude toward death, viewing it as a natural law.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Oh man, death is nothing to fear. Everyone has to go through it\u0026mdash;birth, aging, sickness, and finally death. That\u0026rsquo;s how life is. I\u0026rsquo;ve lived a long life already, and I think when the time comes, I\u0026rsquo;ll be ready to accept it calmly\u0026rdquo;\u003c/em\u003e (P 3)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Death is part of the natural cycle. There is life and there is death, don\u0026rsquo;t be sensitive, don\u0026rsquo;t be afraid.\u0026rdquo;\u003c/em\u003e (P 16)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eNegative emotion about the process of dying\u003c/h2\u003e\u003cp\u003eRather than fearing death itself, participants expressed anxiety about the dying process, particularly the loss of autonomy, prolonged suffering, and dependence on others.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m not afraid of dying. What really scares me is being in a state where I can\u0026rsquo;t talk, can\u0026rsquo;t move, and need someone to feed and clean me. Er\u0026hellip; I\u0026rsquo;ve sent some older adults away, and at that time of death, they can\u0026rsquo;t talk, they can\u0026rsquo;t express their emotions, but they shed tears, and this is emotionally hard ah\u0026hellip;\u0026rdquo;\u003c/em\u003e (P 2)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I could die in my sleep, that would be ideal. But what I dread is a prolonged process\u0026mdash;being bedridden, relying on others for everything, suffering both physically and emotionally. That\u0026rsquo;s my greatest fear.\u0026rdquo;\u003c/em\u003e (P 8)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003ePerception of a good death\u003c/h2\u003e\u003cp\u003eA \u0026ldquo;good death\u0026rdquo; was characterised by the absence of physical or psychological suffering as death nears, with a peaceful and painless dying process (Fan et al., 2019). Participants emphasized a strong desire for a good death.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I hope that when I die it will be easier, with less pain and less suffering. Er\u0026hellip;if I had a very serious illness, I don\u0026rsquo;t want to be in the hospital, especially not in the ICU surrounded by beeping machines. I want to go at home, where I feel comfortable and at peace.\u0026rdquo;\u003c/em\u003e (P 8)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I reach a point where there\u0026rsquo;s no hope. I just want to die straight and fast. Er\u0026hellip;isn\u0026rsquo;t there euthanasia? I think that is just fine, I just want to be euthanised straight away.\u0026rdquo;\u003c/em\u003e (P 1)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Drivers of ACP participation\u003c/h2\u003e\u003cp\u003eThis refers to the benefits ACP offers older adults, close family relationship, and the positive attitudes of healthcare professionals toward ACP.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eReducing unnecessary suffering\u003c/h2\u003e\u003cp\u003eOlder adults identified ACP as a way to prevent unwanted medical interventions and ensure comfort in the final stages of life. Participants emphasized avoiding futile treatment when recovery was unlikely.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I want to avoid meaningless treatments. If my condition can\u0026rsquo;t be reversed, I don\u0026rsquo;t want doctors to keep me alive just for the sake of it. ACP lets me say no to suffering, and that\u0026rsquo;s important to me.\u0026rdquo;\u003c/em\u003e (P 7)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We\u0026rsquo;ve all seen it\u0026mdash;people suffering on ventilators with no chance of recovery. I don\u0026rsquo;t want that. ACP helps ensure I won\u0026rsquo;t be put through that kind of torment if there\u0026rsquo;s no hope left.\u0026rdquo;\u003c/em\u003e (P 9)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eMaintaining dignity\u003c/h2\u003e\u003cp\u003eMaintaining dignity at the end-of-life was a key motivator for ACP engagement. Participants were determined to avoid dependence and indignity in their final moments.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I want to leave this world with some dignity. I don\u0026rsquo;t want to lie there, helpless, with tubes. I want to join ACP so I can leave this world with dignity and a clean body.\u0026rdquo;\u003c/em\u003e (P 2)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Er\u0026hellip;I am a person of dignity, and I am willing to put myself out there through the ACP. I am determined not to drag myself around half dead with no quality of life or dignity.\u0026rdquo;\u003c/em\u003e (P 6)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eEnsuring autonomy in end-of-life decision-making\u003c/h2\u003e\u003cp\u003eParticipants valued the sense of control ACP offered over their own life decisions.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Even if I say what I want now, my children may still disagree later. ACP is official. It ensures that my own voice matters, even if I can\u0026rsquo;t speak for myself.\u0026rdquo;\u003c/em\u003e (P19)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel calmer knowing I can decide my own end. Not leaving it to chance or to others. That gives me peace of mind, especially as I get older.\u0026rdquo;\u003c/em\u003e (P 22)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eReducing the financial and caregiving burden\u003c/h2\u003e\u003cp\u003eParticipants expressed concern about becoming a financial and caregiving burden to their families. ACP was viewed as a proactive step to alleviate these pressures.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Medical bills are so high, and I don\u0026rsquo;t want my children to suffer for me. They already have so much on their plates\u0026mdash;jobs, families, loans. With ACP, I take that pressure off them.\u0026rdquo;\u003c/em\u003e (P 12)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When my time comes, I want it to be simple. No struggling to make decisions, no guilt for my kids. ACP helps ease that for them.\u0026rdquo;\u003c/em\u003e (P 15)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eClose family relationship\u003c/h2\u003e\u003cp\u003eStrong family connections facilitated effective communication on death, allowing older adults to express their personal end-of-life wishes freely.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My daughter and I are very close. We talk about everything\u0026mdash;even my funeral. She knows my wishes, and it gives me comfort that she\u0026rsquo;ll honor them when the time comes.\u0026rdquo;\u003c/em\u003e (P 16)\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eMy wife and I have been classmates since elementary school, and we share a strong bond. My child is also very devoted. Our family is very close, and We\u0026rsquo;ve agreed on no life-sustaining treatments if I\u0026rsquo;m beyond recovery. That openness makes ACP easier.\u003c/em\u003e\u0026rdquo; (P 17)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003ePositive attitudes among healthcare professionals\u003c/h2\u003e\u003cp\u003eEncouragement and information from healthcare providers fostered openness to ACP.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors and nurses need to explain ACP clearly. Many older people don\u0026rsquo;t even know it exists. If professionals guide us, we\u0026rsquo;d feel more confident and less scared of making the wrong decision.\u0026rdquo;\u003c/em\u003e (P 19)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When doctors show they care enough to talk about it, it means a lot. We feel respected. Death is an unknown experience, so we need their insights to help us understand and prepare for what lies ahead.\u0026rdquo;\u003c/em\u003e (P 22)\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eTheme 3: Barriers to ACP participation\u003c/h2\u003e\u003cp\u003eParticipants also highlighted several factors that hindered their involvement in ACP.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eLack of knowledge\u003c/h2\u003e\u003cp\u003eMany participants acknowledged having a limited understanding of ACP, attributing this to insufficient access to information and education on ACP.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Erm\u0026hellip;I\u0026rsquo;ve heard of it, but I don\u0026rsquo;t really know what it means. Is it like writing a will or saying no to treatment? I\u0026rsquo;ve only seen it in movies, not real life.\u0026rdquo;\u003c/em\u003e (P 2)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some say it\u0026rsquo;s like choosing to die, like euthanasia. We need clear explanations, so we\u0026rsquo;re not confused.\u0026rdquo;\u003c/em\u003e (P 6)\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eCultural influence\u003c/h2\u003e\u003cp\u003eCulture profoundly influences attitudes toward illness, death and ACP, with traditional Chinese beliefs often posing barriers to open discussions about end-of-life care.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t want to talk about it. Erm\u0026hellip; it feels negative, pointless, and brings bad luck. I\u0026rsquo;d rather avoid the topic altogether than add to my mental burden.\u0026rdquo;\u003c/em\u003e (P 3)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m not interested in ACP and have no intention of participating. Discussing such matters with others feels inappropriate and unlucky. It only increases the psychological burden for the elderly.\u0026rdquo;\u003c/em\u003e (P 4)\u003c/p\u003e\u003cp\u003eFilial piety and religious beliefs shaped resistance to ACP.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Personally, I\u0026rsquo;d want to join ACP. However, I\u0026rsquo;m concerned that this might clash with my children\u0026rsquo;s values and hinder their ability to fulfill their filial duties. Society would likely judge them negatively for it. So, I\u0026rsquo;m still uncertain.\u0026rdquo;\u003c/em\u003e (P 21)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;My perspective may differ from others... I follow Buddhism. Making decisions about death feels like playing Bodhisattva. I worry that interfering may bring negative karma.\u0026rdquo;\u003c/em\u003e (P 8)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eLack of relevant legal and policies\u003c/h2\u003e\u003cp\u003eThe lack of enforceable laws and standardized ACP policies generated uncertainty about whether personal wishes would be honored.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Does our country have laws that protect the implementation of ACP? If it\u0026rsquo;s not backed by legal protections, then whether I participate or not doesn\u0026rsquo;t really matter.\u0026rdquo;\u003c/em\u003e (P 14)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m still a bit concerned about whether ACP is legally protected. Can it be guaranteed that my wishes will be honoured? What if something goes wrong in the process?\u0026rdquo;\u003c/em\u003e (P 9)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eThe decisive role of family members\u003c/h2\u003e\u003cp\u003eSome participants placed full trust in their family members to make end-of-life decisions, rendering formal ACP plans unnecessary in their view.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Death is a deeply personal matter, and I would only entrust it to those I trust most. All I need to do is make sure my daughter understands my desires, and I\u0026rsquo;m sure she will carry them out as I ask.\u0026rdquo;\u003c/em\u003e (P 8)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Er\u0026hellip;anyway, I\u0026rsquo;ve already shared my thoughts with my son. When the time comes, I\u0026rsquo;ll leave everything to him. Whatever decision he makes, I\u0026rsquo;ll accept it without question.\u0026rdquo;\u003c/em\u003e (P 12)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eNegative attitudes of family members\u003c/h2\u003e\u003cp\u003e Participants often avoided ACP due to emotional resistance from family members who were unwilling to engage in end-of-life conversations.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I once told my daughter I didn\u0026rsquo;t want to go to the hospital if I became seriously ill, but they shut me down, saying not to talk about such things while I\u0026rsquo;m healthy. I haven\u0026rsquo;t brought it up since.\u0026rdquo;\u003c/em\u003e (P 1)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I once mentioned to my wife what I would want to happen if I were to pass away, but she cried and couldn\u0026rsquo;t sleep after. She didn\u0026rsquo;t want to talk about it, so I dropped the subject.\u0026rdquo;\u003c/em\u003e (P 10)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eMistrust toward healthcare professionals\u003c/h2\u003e\u003cp\u003eMistrust toward healthcare professionals also discouraged older adults\u0026rsquo; willingness to participate in ACP, as it directly impacts their belief that future medical care will align with their personal goals and preferences.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It may not make much sense to talk to doctors about death. Doctors see death all the time\u0026hellip;it probably feels routine to them. If I share my fears, they might not take them seriously.\u0026rdquo;\u003c/em\u003e (P 2)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctors are trained to save lives. Even if I say I don\u0026rsquo;t want resuscitation, they might still try. I\u0026rsquo;m not sure they\u0026rsquo;d truly follow my wishes.\u0026rdquo;\u003c/em\u003e (P 8)\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTheme 4: Strategies for promoting ACP participation\u003c/h3\u003e\n\u003cp\u003eParticipants suggested that optimal timing, face-to-face with audio-visual aid, and inclusion of family members could all be effective ways to encourage older adults to participate in ACP.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eOptimal timing\u003c/h2\u003e\u003cp\u003eMost participants agreed that ACP conversations should start early, when they are still healthy and cognitively capable of making clear decisions.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe it\u0026rsquo;s better to start early, while I\u0026rsquo;m still healthy and can approach it more rationally and objectively. That way, I\u0026rsquo;ll be more prepared if I become seriously ill later.\u0026rdquo;\u003c/em\u003e (P 18)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s best to have this conversation sooner rather than later. As I age, both my body and mind are deteriorating. Discussing it sooner helps me decide with a clear mind. If I wait until I\u0026rsquo;m very sick, I might not think properly.\u0026rdquo;\u003c/em\u003e (P 22)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eFace-to-face with audio-visual aid\u003c/h2\u003e\u003cp\u003eDirect interaction combined with visual aids was considered an effective approach for promoting understanding and comfort in discussing ACP.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;ACP should be approached with care. It\u0026rsquo;s important to have a face-to-face conversation, and if the older person isn\u0026rsquo;t in the right frame of mind, it\u0026rsquo;s best to stop. Additionally, providing audiovisual materials with pictures also help older adults understand better.\u0026rdquo;\u003c/em\u003e (P 2)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe face-to-face communication is more personal. If something is unclear, we can address it immediately, which makes it easier to understand. But since doctors are busy, videos or picture-based pamphlets could help us learn too.\u0026rdquo;\u003c/em\u003e (P 11)\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eInclusion family members\u003c/h2\u003e\u003cp\u003eEngaging family members in ACP discussions was seen as essential for creating a supportive environment and reducing emotional discomfort for the older adult.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I believe the promotion of ACP shouldn\u0026rsquo;t focus solely on the elderly; it could feel harsh to them\u0026hellip;It should involve families too. With their support, discussing ACP with doctors would feel less stressful.\u0026rdquo;\u003c/em\u003e (P 18)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;ACP should be something not just for seniors, but for their family members too! I\u0026rsquo;d like to learn about it with my family so we can talk and decide together.\u0026rdquo;\u003c/em\u003e (P 20)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers valuable insights into the complex factors influencing participation ACP among older adults. By incorporating the perspectives, several key dimensions were identified that shape ACP participation. Similar qualitative research from countries such as the United States, Australia, England, Sweden, and the Netherlands has also underscored the importance of individual-level influences on ACP participation (Combes et al., 2021). However, our findings highlight the need for more comprehensive evidence to deepen understanding of the drivers and barriers affecting ACP participation, particularly in Chinese contexts.\u003c/p\u003e\u003cp\u003eThe theme of perspective of death revealed that the older adults held mixed views. Many regarded death itself as a natural and inevitable process, often with a sense of calm and acceptance, echoing prior research (\u0026Ouml;sterlind et al., 2017). However, this study further found that participants expressed negative emotions when considering the dying process, particularly regarding pain and prolonged suffering, aligning with prior researches that highlighted the distinction between fears of dying versus death (Fleming et al., 2016; Tjernberg \u0026amp; B\u0026ouml;kberg, 2020). This fear may stem from a lack of opportunities to discuss dying despite their interest in such conversations. Additionally, participants expressed the desire for a good death, characterised by a peaceful passing devoid of suffering (Fan et al., 2019). This aligns with broader cultural ideals (Tipwong et al., 2022) and underscores the potential role of ACP in mitigating death anxiety.\u003c/p\u003e\u003cp\u003eThe theme of drivers of ACP participation illustrates several motivating factors. Self-concern was a primary motivator, with participants seeking to reduce unnecessary suffering, maintain dignity and ensure autonomy in end-of-life decision-making. As populations age, safeguarding comfort and dignity at the end-of-life becomes increasingly vital (Hadley et al., 2017; Jin et al., 2022). Participants viewed ACP as a means to avoid painful and non-beneficial interventions in terminal conditions (KrakauerEric, 2024; Shaowei, 2021). In Chinese culture, dignity in death is highly valued (Li \u0026amp; Li, 2017). Participants felt ACP as a way to uphold this dignity and ensure that personal values were respected, consistent with both quantitative and qualitative findings (Lall et al., 2021; Yi et al., 2021). Older adults also valued ACP as a way to retain control over their healthcare decisions, ensuring that care aligned with their personal values, aligning with research showing a growing desire for autonomy in healthcare with age (Moilanen et al., 2021).\u003c/p\u003e\u003cp\u003eFamily-centered considerations also played a critical role. Participants noted that ACP could help alleviate the financial burden and caregiving pressure on families, particularly in the context of China\u0026rsquo;s one-child policy, where children face heavier economic and caregiving responsibilities (Cai \u0026amp; Feng, 2021). This aligns with the findings of a prior quantitative study (Gao et al., 2025). However, this study revealed that older adults with overly cohesive family ties might hesitate to engage in ACP, fearing that conversations about death would burden their loved ones emotionally. Additionally, some older adults tended to over-rely on family members to make decisions on their behalf, leading to their complete withdrawal from ACP discussions. Therefore, it is crucial to encourage family members to respect the autonomy of older adults and to foster an inclusive and supportive family environment that balances care with individual decision-making.\u003c/p\u003e\u003cp\u003eThe positive attitude among healthcare professionals toward ACP also emerged as critical. Participants appreciated guidance from trusted providers, which improved their understanding of medical options and the value of ACP. This finding aligns with studies suggesting that clinician-initiated discussions and ongoing provider engagement are crucial for successful ACP implementation (Cattagni Kleiner et al., 2019; Fleuren et al., 2021; Howard et al., 2018).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe third theme elucidated key barriers that hinder older adults\u0026rsquo; participation in ACP. A lack of knowledge of ACP was a predominant obstacle. This finding mirrors trends observed in other Asian countries, such as South Korea (Lee et al., 2018), China (Gao et al., 2025), Japan (Kawakami et al., 2021), and Singapore (Tang et al., 2023), where ACP is still relatively novel. As seen in previous studies, individuals\u0026rsquo; understanding of ACP is crucial for their participation (Sung et al., 2019; Yi \u0026amp; Hohashi, 2018). Educating patients about their treatment choices and the implications of various end-of-life options not only helps shape their care preferences but also significantly increases the likelihood of ACP acceptance.\u003c/p\u003e\u003cp\u003eAlthough prior quantitative research suggested that cultural factors were not associated with willingness to engage in ACP (Gao et al., 2025), the present study reveals cultural factors also influence older adults\u0026rsquo; participating in ACP. While Western values of autonomy and open discussion, Confucian norms emphasize filial piety and avoid death-related conversations (Xu et al., 2023; Yang et al., 2021). In addition, religious beliefs, such as Buddhist views on natural death, may also reduce receptiveness to ACP (Tipwong et al., 2022; Upasen et al., 2022). These findings underscore the need to strengthen death education and foster a more scientific and open understanding of death.\u003c/p\u003e\u003cp\u003eLack of relevant legal and policies further constrain ACP uptake. Studies have demonstrated that legislative support positively influences ACP participation rates (Prince-Paul \u0026amp; DiFranco, 2017; Senda et al., 2018). According to Zhu. et al. (2020), China lacks national policies or standardized procedures, undermining trust and limiting implementation. In addition, some participants indicated that the decisive role of family members also deters ACP. Many participants preferred family members to make end-of-life choices, believing they would act in their best interest (Fan et al., 2019). This aligns with cultural norms in China, where familial authority often supersedes individual autonomy (Pei et al., 2021). A systematic review also noted that older adults may not want to participate in ACP if they are highly dependent on family members for decision-making (Musa et al., 2015).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAdditionally, the mistrust toward healthcare professionals also emerged as a significant barrier. Limited patient\u0026ndash;provider interaction, inadequate follow-up care, and avoidance of death-related discussions contribute to this distrust (Howard et al., 2018; Tang et al., 2023). Notably, one study reported that only 5.9% of older adults had discussed ACP with their healthcare professionals (Cattagni Kleiner et al., 2019), and perceptions of healthcare professionals\u0026rsquo; insensitivity or disregard for patient preferences further discourage engagement (van Dyck et al., 2021), underscoring the need for improved healthcare professionals training.\u003c/p\u003e\u003cp\u003eFinally, the fourth theme addressed the strategies for promoting ACP participation. Participants emphasised the importance of optimal timing, identifying it as the ideal moment to initiate discussions about end-of-life care (Chi et al., 2018). Many preferred to address ACP as early as possible, ideally before cognitive or psychological decline, consistent with previous research showing that early engagement facilitates better planning outcomes (Chi et al., 2018). Preferences for face-to-face discussions supplemented with audio-visual aids was frequently cited. While traditional formats rely on verbal or written materials (Kavalieratos et al., 2015), integrating integrating audio-visual aids can improve comprehension and personalize decision-making (Hendricks Sloan et al., 2016). Given the deeply personal nature of ACP, which reflects individual beliefs and experiences, face-to-face communication is the most effective approach (Kavalieratos et al., 2015). These methods are especially helpful for older adults facing physical or digital challenges.\u003c/p\u003e\u003cp\u003eThe involvement of family members was considered essential. In Chinese culture, where end-of-life decisions are typically made collectively, family support is vital to ACP participation (Michael et al., 2017; Wang et al., 2022). Educating family members can help normalize ACP discussions, reduce stigma, and foster a supportive environment for older adults to express their preferences more openly.\u003c/p\u003e\n\u003ch3\u003eStrengths and Limitations\u003c/h3\u003e\n\u003cp\u003eThe strengths of this study are purposive sampling and methodological triangulation. Purposive sampling allowed for the selection of participants with diverse demographic backgrounds, ensuring a heterogeneous sample of older adults residing in community settings in China. Triangulation further enhanced the study\u0026rsquo;s credibility. Two independent observers reviewed the study design, interview procedures, and thematic analysis. This helped to avoid personal bias and promoted self-reflection throughout the research process, enabling researchers to gain comprehensive insights.\u003c/p\u003e\u003cp\u003eLimitations include the fact that most interview participants were in relatively good health, which may have introduced bias and limited the transferability of the findings. Future research should include participants with a broader range of health conditions to capture more diverse and representative perspectives.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results of this study contribute to a deeper understanding of drivers and barriers to ACP participation among community-dwelling older adults in China. It highlights the importance of strengthening death education and engaging family members in supporting the ACP process. By recognizing the multifaceted factors that influence participation in ACP, targeted interventions can be developed to encourage engagement among older adults and advance the implementation of ACP in China.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. The study was approved by the Ethics Committee of Sichuan Provincial People\u0026rsquo;s Hospital (Approval ID: 20240421). Informed consent was obtained from all participants included in the study which was a completely voluntary, anonymous, and unrewarded study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study will be shared only on request with the approval from the Universiti Malaya thesis Unit. Plesease contacted corresponding author if needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Chengdu Municipal Health Commission (2024442) and the Scientific Research Project of Sichuan Cadre Health Committee (2023-225). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFG: Conceptualization, Methodology, Data Collation, Formal Analysis, Role/Writing - Original Manuscript, Project Administration\u003c/p\u003e\n\u003cp\u003eKW: Conceptualization, Methodology, Formal Analysis, Resources.\u003c/p\u003e\n\u003cp\u003eLX: Conceptualization, Methodology, Original Manuscript, Resources.\u003c/p\u003e\n\u003cp\u003eCCC: Conceptualization, Supervision.\u003c/p\u003e\n\u003cp\u003eRH: Conceptualization, Methodology, Original Manuscript, Resources. \u0026nbsp;CPL and MFL: Supervision and Writing - Review.\u003c/p\u003e\n\u003cp\u003eAll authors: Validation, Writing - Review and Editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhmed, S. K. (2024). The pillars of trustworthiness in qualitative research. \u003cem\u003eJournal of Medicine, Surgery, and Public Health\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e, 100051.\u003c/li\u003e\n \u003cli\u003eCai, Y., \u0026amp; Feng, W. (2021). The social and sociological consequences of China\u0026apos;s one-child policy. \u003cem\u003eAnnual review of sociology\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e(1), 587\u0026ndash;606.\u003c/li\u003e\n \u003cli\u003eCattagni Kleiner, Anne Santos-Eggimann, Brigitte Fustinoni, Sarah D\u0026uuml;rst, Anne-V\u0026eacute;ronique Haunreiter, Katja Rubli-Truchard, \u0026amp; Seematter-Bagnoud, E. (2019). Advance care planning dispositions: the relationship between knowledge and perception. \u003cem\u003eBMC geriatrics\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e, 1\u0026ndash;11.\u003c/li\u003e\n \u003cli\u003eChi, H.-L., Cataldo, J., Ho, E. Y., \u0026amp; Rehm, R. S. (2018). Can we talk about it now? Recognizing the optimal time to initiate end-of-life care discussions with older Chinese Americans and their families. \u003cem\u003eJournal of transcultural nursing\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(6), 532\u0026ndash;539.\u003c/li\u003e\n \u003cli\u003eCombes, S., Gillett, K., Norton, C., \u0026amp; Nicholson, C. J. (2021). The importance of living well now and relationships: a qualitative study of the barriers and enablers to engaging frail elders with advance care planning. \u003cem\u003ePalliative medicine\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(6), 1137\u0026ndash;1147.\u003c/li\u003e\n \u003cli\u003eDaniel, B. K. (2019). Student experience of the maximum variation framework for determining sample size in qualitative research. 18th European conference on research methodology for business and management studies,\u003c/li\u003e\n \u003cli\u003eEryılmaz, \u0026Ouml;. (2022). Are dissertations trustworthy enough? The case of Turkish ph. d. dissertations on social studies education. \u003cem\u003eParticipatory Educational Research\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(3), 344\u0026ndash;361.\u003c/li\u003e\n \u003cli\u003eFan, S. Y., Sung, H. C., \u0026amp; Wang, S. C. (2019). The experience of advance care planning discussion among older residents in a long-term care institution: A qualitative study. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(19\u0026ndash;20), 3451\u0026ndash;3458.\u003c/li\u003e\n \u003cli\u003eFleming, J., Farquhar, M., Collaboration, C. C. o.-s. C. S., Brayne, C., \u0026amp; Barclay, S. (2016). Death and the oldest old: attitudes and preferences for end-of-life care-qualitative research within a population-based cohort study. \u003cem\u003ePlos one\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(4), e0150686.\u003c/li\u003e\n \u003cli\u003eFleuren, N., Depla, M. F., Pasman, H. R. W., Janssen, D. J., Onwuteaka-Philipsen, B. D., Hertogh, C. M., \u0026amp; Huisman, M. (2021). Association between subjective remaining life expectancy and advance care planning in older adults: a cross-sectional study. \u003cem\u003eJournal of pain and symptom management\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(4), 757\u0026ndash;767.\u003c/li\u003e\n \u003cli\u003eGao, F., Chui, P. L., Che, C. C., \u0026amp; Wang, K. (2025). The mediating role of family cohesion in the relationship between death anxiety and readiness toward advance care planning among Chinese community-dwelling older adults: A cross-sectional study. \u003cem\u003eGeriatric Nursing\u003c/em\u003e, \u003cem\u003e61\u003c/em\u003e, 192\u0026ndash;199.\u003c/li\u003e\n \u003cli\u003eGao, F., Chui, P. L., Che, C. C., Xiao, L., \u0026amp; Zhang, Q. (2024). Advance care planning readiness among community-dwelling older adults and the influencing factors: a scoping review. \u003cem\u003eBMC Palliative Care\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 255.\u003c/li\u003e\n \u003cli\u003eGibbs, G. (2007). Thematic Coding and Categorizing. In (pp. 38\u0026ndash;56): Analyzing qualitative data,.\u003c/li\u003e\n \u003cli\u003eHadley, E. C., Kuchel, G. A., Newman, A. B., Allore, H. G., Bartley, J. M., Bergeman, C. S., Blinov, M. L., Colon-Emeric, C. S., Dabhar, F. S., \u0026amp; Dugan, L. L. (2017). Report: NIA workshop on measures of physiologic resiliencies in human aging. \u003cem\u003eThe Journals of Gerontology: Series A\u003c/em\u003e, \u003cem\u003e72\u003c/em\u003e(7), 980\u0026ndash;990.\u003c/li\u003e\n \u003cli\u003eHan, S., Li, H., \u0026amp; Xia, L. (2018). Implementation and research progress of Advance Care Planning: a review. \u003cem\u003eChinese Nursing Management\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(3), 298\u0026ndash;302.\u003c/li\u003e\n \u003cli\u003eHendricks Sloan, D., Peters, T., Johnson, K. S., Bowie, J. V., Ting, Y., \u0026amp; Aslakson, R. (2016). Church-based health promotion focused on advance care planning and end-of-life care at Black Baptist churches: a cross-sectional survey. \u003cem\u003eJournal of Palliative Medicine\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(2), 190\u0026ndash;194.\u003c/li\u003e\n \u003cli\u003eHoward, M., Bernard, C., Klein, D., Tan, A., Slaven, M., Barwich, D., You, J. J., Asselin, G., Simon, J., \u0026amp; Heyland, D. K. (2018). Older patient engagement in advance care planning in Canadian primary care practices: Results of a multisite survey. \u003cem\u003eCan Fam Physician\u003c/em\u003e, \u003cem\u003e64\u003c/em\u003e(5), 371\u0026ndash;377.\u003c/li\u003e\n \u003cli\u003eHu, J.-b., Zhou, W.-h., Hu, S.-h., Huang, M.-l., Wei, N., Qi, H.-l., Huang, J.-w., \u0026amp; Xu, Y. (2013). Cross-cultural difference and validation of the Chinese version of Montreal Cognitive Assessment in older adults residing in Eastern China: preliminary findings. \u003cem\u003eArchives of Gerontology and Geriatrics\u003c/em\u003e, \u003cem\u003e56\u003c/em\u003e(1), 38\u0026ndash;43.\u003c/li\u003e\n \u003cli\u003eJin, S., Liu, S., Li, J., Ning, X., \u0026amp; Liu, X. (2022). Stumbling and Growing: A Bibliometric Study of Academic Publications of Palliative Care in Mainland China for 2010\u0026ndash;2020. \u003cem\u003eJournal of Palliative Care\u003c/em\u003e, 08258597211039056.\u003c/li\u003e\n \u003cli\u003eKavalieratos, D., Ernecoff, N. C., Keim-Malpass, J., \u0026amp; Degenholtz, H. B. (2015). Knowledge, attitudes, and preferences of healthy young adults regarding advance care planning: a focus group study of university students in Pittsburgh, USA. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e, 1\u0026ndash;7.\u003c/li\u003e\n \u003cli\u003eKawakami, A., Kwong, E. W., Lai, C. K., Song, M. S., Boo, S., \u0026amp; Yamamoto-Mitani, N. (2021). Advance care planning and advance directive awareness among East Asian older adults: Japan, Hong Kong and South Korea. \u003cem\u003eGeriatrics \u0026amp; gerontology international\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 71\u0026ndash;76.\u003c/li\u003e\n \u003cli\u003eKelley, A. S., \u0026amp; Morrison, R. S. (2015). Palliative care for the seriously ill. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e, \u003cem\u003e373\u003c/em\u003e(8), 747\u0026ndash;755.\u003c/li\u003e\n \u003cli\u003eKhokhar, S., Pathan, H., Raheem, A., \u0026amp; Abbasi, A. M. (2020). Theory development in thematic analysis: Procedure and practice. \u003cem\u003eReview of Applied Management and Social Sciences\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(3), 423\u0026ndash;433.\u003c/li\u003e\n \u003cli\u003eKrakauer, E. L. (2024). How to Respond Responsibly to Suffering of Others? Rethinking Palliative Care for China. \u003cem\u003eMedical Journal of Peking Union Medical College Hospital\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 7\u0026ndash;11.\u003c/li\u003e\n \u003cli\u003eKrakauerEric, L. (2024). How to Responsibly Respond to Others\u0026apos; Suffering? \u0026mdash; Rethinking Palliative Care in China. \u003cem\u003eMedical Journal of Peking Union Medical College Hospital\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 7\u0026ndash;11.\u003c/li\u003e\n \u003cli\u003eLall, P., Dutta, O., Tan, W. S., Patinadan, P. V., Kang, N. Q., Low, C. K., Car, J., \u0026amp; Ho, A. H. Y. (2021). \u0026ldquo;I decide myself\u0026rdquo;-A qualitative exploration of end of life decision making processes of patients and caregivers through Advance Care Planning. \u003cem\u003ePlos one\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(6), e0252598.\u003c/li\u003e\n \u003cli\u003eLee, J. E., Shin, D. W., Son, K. Y., Park, H. J., Lim, J.-Y., Song, M. S., Park, Y.-H., \u0026amp; Cho, B. (2018). Factors influencing attitudes toward advance directives in Korean older adults. \u003cem\u003eArchives of Gerontology and Geriatrics\u003c/em\u003e, \u003cem\u003e74\u003c/em\u003e, 155\u0026ndash;161.\u003c/li\u003e\n \u003cli\u003eLi, Y., \u0026amp; Li, J. (2017). Death with dignity from the Confucian perspective. \u003cem\u003eTheoretical Medicine and Bioethics\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e, 63\u0026ndash;81.\u003c/li\u003e\n \u003cli\u003eLiao, J., Wu, B., Ni, P., \u0026amp; Mao, J. (2019). Advance directive preferences among terminally ill older patients and its facilitators and barriers in China: a scoping review. \u003cem\u003eJournal of the American Medical Directors Association\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(11), 1356\u0026ndash;1361. e1352.\u003c/li\u003e\n \u003cli\u003eMichael, N., O\u0026rsquo;Callaghan, C., \u0026amp; Sayers, E. (2017). Managing \u0026lsquo;shades of grey\u0026rsquo;: a focus group study exploring community-dwellers\u0026rsquo; views on advance care planning in older people. \u003cem\u003eBMC Palliative Care\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e, 1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eMoilanen, T., Kangasniemi, M., Papinaho, O., Mynttinen, M., Siipi, H., Suominen, S., \u0026amp; Suhonen, R. (2021). Older people\u0026rsquo;s perceived autonomy in residential care: An integrative review. \u003cem\u003eNursing ethics\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(3), 414\u0026ndash;434.\u003c/li\u003e\n \u003cli\u003eMunhall, P. (2012). \u003cem\u003eNursing research\u003c/em\u003e. Jones \u0026amp; Bartlett Learning.\u003c/li\u003e\n \u003cli\u003eMusa, I., Seymour, J., Narayanasamy, M. J., Wada, T., \u0026amp; Conroy, S. (2015). A survey of older peoples\u0026rsquo; attitudes towards advance care planning. \u003cem\u003eAge and ageing\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(3), 371\u0026ndash;376.\u003c/li\u003e\n \u003cli\u003eNedjat-Haiem, F. R., Carrion, I. V., Gonzalez, K., Bennett, E. D., Ell, K., O\u0026rsquo;Connell, M., Thompson, B., \u0026amp; Mishra, S. I. (2018). Exploring motivational interviewing to engage Latinos in advance care planning: a community-based social work intervention. \u003cem\u003eAmerican Journal of Hospice and Palliative Medicine\u0026reg;\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(8), 1091\u0026ndash;1098.\u003c/li\u003e\n \u003cli\u003eOrganization, W. H. (2025). \u003cem\u003eAgeing and health in China\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003e\u0026Ouml;sterlind, J., Ternestedt, B. M., Hansebo, G., \u0026amp; Hellstr\u0026ouml;m, I. (2017). Feeling lonely in an unfamiliar place: older people\u0026rsquo;s experiences of life close to death in a nursing home. \u003cem\u003eInternational Journal of Older People Nursing\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(1), e12129.\u003c/li\u003e\n \u003cli\u003ePei, Y., Zhang, W., \u0026amp; Wu, B. (2021). Advance care planning engagement and end-of-life preference among older Chinese Americans: do family relationships and immigrant status matter? \u003cem\u003eJournal of the American Medical Directors Association\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(2), 340\u0026ndash;343.\u003c/li\u003e\n \u003cli\u003ePrince-Paul, M., \u0026amp; DiFranco, E. (2017). Upstreaming and normalizing advance care planning conversations\u0026mdash;a public health approach. \u003cem\u003eBehavioral sciences\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(2), 18.\u003c/li\u003e\n \u003cli\u003eSenda, K., Nishikawa, M., Miura, H., \u0026amp; Arai, H. (2018). There is something about advance care planning: Report on Dr Karen Detering\u0026apos;s lecture on advance care planning at the Annual Meeting of the Japan Geriatrics Society, 2018. \u003cem\u003eGeriatrics \u0026amp; gerontology international\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(12).\u003c/li\u003e\n \u003cli\u003eShaowei, W. Y. X. H. L. (2021). A comparison of end-of-life care preferences between nursing home residents and community-dwellers. \u003cem\u003eChina Journal Nursing\u003c/em\u003e, \u003cem\u003eApril 2021, Vol. 56, No. 4\u003c/em\u003e, 567\u0026ndash;573.\u003c/li\u003e\n \u003cli\u003eShen, X., Zhou, S., \u0026amp; Zhang, X. (2022). \u003cem\u003eServices for Aging Persons in China\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/978-3-030-98032-0\u003c/span\u003e\u003c/span\u003e (Global Perspectives on Health Geography)\u003c/li\u003e\n \u003cli\u003eSudore, R. L., Lum, H. D., You, J. J., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Matlock, D. D., Rietjens, J. A., Korfage, I. J., \u0026amp; Ritchie, C. S. (2017). Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel. \u003cem\u003eJournal of pain and symptom management\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(5), 821\u0026ndash;832. e821.\u003c/li\u003e\n \u003cli\u003eSung, H.-C., Wang, S.-C., Fan, S.-Y., \u0026amp; Lin, C.-Y. (2019). Advance care planning program and the knowledge and attitude concerning palliative care. \u003cem\u003eClinical Gerontologist\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e(3), 238\u0026ndash;246.\u003c/li\u003e\n \u003cli\u003eTang, J. M. S., Cher, B. X. B. B., Lim, S. F., \u0026amp; Siah, C. J. R. (2023). A meta-synthesis on the older adults\u0026apos; perspective of advance care planning. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(13\u0026ndash;14), 4176\u0026ndash;4194.\u003c/li\u003e\n \u003cli\u003eTipwong, A., Ruamsook, T., Hongkittiyanon, T., \u0026amp; Kgowsiri, K. (2022). The perceptions on good death of the older adults in the semi-urban community: A qualitative study. \u003cem\u003eInternational Journal of Nursing Sciences\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(3), 389\u0026ndash;396.\u003c/li\u003e\n \u003cli\u003eTjernberg, J., \u0026amp; B\u0026ouml;kberg, C. (2020). Older persons\u0026rsquo; thoughts about death and dying and their experiences of care in end-of-life: a qualitative study. \u003cem\u003eBMC nursing\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e, 1\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003eTong, A., Sainsbury, P., \u0026amp; Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. \u003cem\u003eInternational Journal for Quality in Health Care\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(6), 349\u0026ndash;357.\u003c/li\u003e\n \u003cli\u003eUpasen, R., Thanasilp, S., Akkayagorn, L., Chimluang, J., Tantitrakul, W., Doutrich, D. L., \u0026amp; Saengpanya, W. (2022). Death acceptance process in Thai Buddhist patients with life-limiting cancer: A grounded theory. \u003cem\u003eGlobal Qualitative Nursing Research\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e, 23333936221111809.\u003c/li\u003e\n \u003cli\u003evan Dyck, L. I., Paiva, A., Redding, C. A., \u0026amp; Fried, T. R. (2021). Understanding the role of knowledge in advance care planning engagement. \u003cem\u003eJournal of pain and symptom management\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(4), 778\u0026ndash;784.\u003c/li\u003e\n \u003cli\u003eWang, K., Sun, F., Liu, Y., Kong, D., \u0026amp; De Fries, C. M. (2022). Attitude toward family involvement in end-of-life care among older Chinese Americans: how do family relationships matter? \u003cem\u003eJournal of Applied Gerontology\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(2), 380\u0026ndash;390.\u003c/li\u003e\n \u003cli\u003eXu, X., Chau, P. H., Cheung, D. S. T., Ho, M. H., \u0026amp; Lin, C. C. (2023). Preferences for end-of‐life care: A cross‐sectional survey of Chinese frail nursing home residents. \u003cem\u003eJournal of Clinical Nursing\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(7\u0026ndash;8), 1455\u0026ndash;1465.\u003c/li\u003e\n \u003cli\u003eYang, Z., Hou, B., Chen, P., \u0026amp; Zhang, H. (2021). Preference and influencing factors of advance care planning for Chinese elderly patients with chronic diseases: a mixed-methods approach. \u003cem\u003eJournal of Hospice \u0026amp; Palliative Nursing\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(2), 178\u0026ndash;186.\u003c/li\u003e\n \u003cli\u003eYi, Q., \u0026amp; Hohashi, N. (2018). Comparison of perceptions of domestic elder abuse among healthcare workers based on the Knowledge-Attitude-Behavior (KAB) model. \u003cem\u003ePlos one\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(11), e0206640.\u003c/li\u003e\n \u003cli\u003eYi, Y. C., Nu, L. C., Cheng, Y. C., Fei, T. Z., Rong, H. Y., Min, S. F., Chiao, H. F., \u0026amp; Jen, L. C. (2021). Insisting on Life Dignity: Advance Care Planning in Taiwan During COVID-19 Pandemic.\u003c/li\u003e\n \u003cli\u003eZhu, T., Zhang, J., Shi, Y., Yi, J., Zhang, Q., Zhao, Y., Gao, Q., Wang, Z., Li, J., \u0026amp; Liu, X. (2020). Awareness and attitudes toward advance care planning among community-dwelling older adults in China: a mixed-methods study. \u003cem\u003eAmerican Journal of Hospice and Palliative Medicine\u0026reg;\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(9), 743\u0026ndash;749.\u003c/li\u003e\n \u003cli\u003eZhu., Zhang, J., Shi, Y., Yi, J., Zhang, Q., Zhao, Y., Gao, Q., Wang, Z., Li, J., Liu, X., \u0026amp; Liu, D. (2020). Awareness and Attitudes Toward Advance Care Planning Among Community-Dwelling Older Adults in China: A Mixed-Methods Study. \u003cem\u003eAm J Hosp Palliat Care\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(9), 743\u0026ndash;749. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1049909120905255\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"advance care planning, barrier, driver, older adults, qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-7425642/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7425642/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eAdvance care planning (ACP) is effective in enhancing the quality of life during older adults’ end-of-life stage. However, ACP remains a novel concept in China, and the inclination of community-dwelling older adults towards ACP participation remains uncertain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eTo explore the factors that promote or hinderparticipating in ACP from the perspectives of Chinese community-dwelling older adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e This was a descriptive qualitative study that incorporated semi-structured interviews.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Purposive sampling was used to enlist a total of 22 older adults residing in four communities in Chengdu, China. The data were transcribed verbatim and analysed using thematic analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The analysis identified four main themes and eighteen subthemes that influenced older adults’ participation in ACP. The four themes were: perspective on death, drivers of ACP participation, barriers to participation, and strategies to promote engagement in ACP.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This study highlights drivers and barriers to ACP participation among community-dwelling older adults in China, offering valuable insights for developing targeted interventions to support ACP implementation. Enhanced mortality education and involvement of family members play an important role in promoting ACP engagement.\u003c/p\u003e","manuscriptTitle":"Drivers and barriers to participate in advance care planning: insights from Chinese community-dwelling older adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-08 03:49:15","doi":"10.21203/rs.3.rs-7425642/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-09-26T04:49:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-23T09:49:12+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-04T16:40:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-03T16:04:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2025-09-03T16:01:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bfc02453-b1c6-49fa-a98e-3be3f0652f83","owner":[],"postedDate":"October 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-08T03:49:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-08 03:49:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7425642","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7425642","identity":"rs-7425642","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}