Mapping Advance Care Planning and Advance Directives in Latin America

Mapping Advance Care Planning and Advance Directives in Latin America | 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 Mapping Advance Care Planning and Advance Directives in Latin America Natália Rocha Tardelli, Fernanda Bono Fukushima, Jenny T. van der Steen, and 24 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4523931/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Sep, 2025 Read the published version in BMC Palliative Care → Version 1 posted 15 You are reading this latest preprint version Abstract Background/aims It is unclear whether or how low- and middle-income countries have implemented Advance Care Planning (ACP) and Advance Directives (AD). We aimed to map the current state of ACP/AD in Latin America. Methods This cross-sectional mixed-methods survey of ACP/AD in LA comprised interviews with 18 key informants from 18 out of 20 countries, most of whom were appointed by national Palliative Care Associations. Interviews occurred online with each informant encompassing various issues ranging from AD regulations to ACP/AD in the context of end-of-life clinical decision making. We performed member checking and data triangulation to confirm our findings. Results Only eight (44%) countries have some form of ACP/AD regulations. Most regulatory frameworks tend to adopt a legalistic pattern heavily influenced by the North American model. Despite that characteristic of AD regulations in LA, the leading strategy used by patients to avoid unwanted treatment at the end of life is through conversations with their families, whereas the least common strategy was consulting with a lawyer. In six (33%) countries, informants believed it was common for patients to grant their families with permission to modify their previous choices regarding future treatments. The religiousness/spirituality of populations plays an important role regarding the implementation of ACP in the region. Additionally, respecting patients’ preferences of care at the end of life appears to be tied more to aspects related to the characteristics of doctor-patient relationship, and the degree of integration of palliative care into the healthcare system than the existence or content of AD regulations. There was consensus that none of the countries provide sufficient education about ACP/AD to healthcare professionals. Conclusions Our findings encourage rethinking ACP/AD in LA from a decolonial perspective, considering characteristics such as the preference for a relational model of autonomy in several countries and the importance of taking the religiousness/spirituality of individuals into account during ACP conversations. Our data also suggest that honoring patients’ preferences of care at the end of life entails integrating palliative care into health care systems, educating healthcare professionals and the population, and fostering longitudinal trusting relationships between those professionals with patients and their families. Advance Care Planning Advance Directives Palliative Care Aging Cross-sectional studies Latin America Figures Figure 1 Figure 2 BACKGROUND The combination of population ageing and the increase in non-communicable diseases has contributed to a rising global burden of serious health-related suffering, underscoring the need for improved access to palliative care (PC).[ 1 ] Worldwide, the years lived without good health have increased from 8.6 years to 10 years between 2000 and 2019.[ 2 ] In 2015, 25 million people died experiencing serious health-related suffering, with 80% of these cases occurring in low- and middle-income countries (LMICs).[ 1 ] In LA, between 1990 and 2019, life expectancy at age 65 increased from 17.1 years to 19.2 whereas increases in healthy life expectancy were much lower (from 12.2 to 13 years).[ 3 ] The current number of Latinos aged 65 years and older is 56.4 million, and it is expected that this number will grow 156% by 2050, reaching 20% of the entire population, with an expected life expectancy of 82 years in 2050.[ 4 , 5 ] LA comprises 20 countries, with most of them being middle-income nations, characterized by limited PC availability compared to high-income countries [ 6 – 12 ] Therefore, the expected increase in PC demand is a cause for concern. A key tenet of PC to reduce the suffering of people living with serious illnesses and their families involves aligning treatments with the values and preferences of care of patients/families. The absence of such alignment poses the risk of medical interventions aimed at decreasing suffering resulting the opposite – inadvertently increased suffering.[ 13 ] Advance Care Planning (ACP) is considered one of the most important means to achieve that kind of alignment. ACP was defined by an international Delphi consensus as a process that supports adults at any age or stage of health in understanding and sharing their values, life goals, and preferences regarding future medical care.[ 14 ] Its importance is related to the common scenario where patients approach the end of life, become unable to speak for themselves, and are no longer able to provide informed consent or participate in shared decision-making. Indeed, ACP is considered an important component of PC from the time of diagnosis and continuing through the illness process.[ 15 ] However, the concepts of ACP and Advance Directives (AD) were developed primarily in high-income countries[ 16 ] from the global North and it is unclear how those concepts have been implemented (or not) in low- and middle-income countries across various regions of the world. Latin American countries exhibit diverse cultural, legal, and socioeconomic characteristics that likely influence the adoption and implementation of ACP/AD in each country ( Supplementary Material 1, Figure S1 , Table S1 ). Despite efforts to assess the state of PC in LA through the Latin American Atlas of Palliative Care,[ 12 , 17 ] to date, there has been no corresponding initiative to map the state of ACP in this region. As the Atlas played an important role in understanding the strengths, weaknesses and local needs of each Latin American country, we believe that mapping the state of ACP in LA will be instrumental in tailoring ACP interventions to the region’s specific characteristics. Furthermore, a recent Delphi study identified ACP/AD as one of the research priorities in PC for LA.[ 18 ] This research aims to provide an overview of the current state of ACP in LA in terms of regulations, level of education of healthcare professionals on these subjects, knowledge and perception of the country’s population on ACP/AD, how those concepts are put into practice, and their use in the context of clinical decision making at the end of life, with the hope that such information can contribute to the progress of ACP and PC in these countries. METHODS Study Design This is a cross-sectional survey of ACP/AD in LA using a mixed-methods approach. The reporting followed the Consensus-Based Checklist for Reporting of Survey Studies (CROSS).[ 19 ] Participants We searched the internet for all national PC associations in each of the 20 LA countries and sent them invitations by email to participate in this research. We asked each association to appoint a key informant to provide us with information about the state of ACP in their countries. When a country did not have a national PC association, or when that association did not respond to our invitation, we sent emails to researchers who collaborated with the Atlas of Palliative Care in LA [ 12 ] members of the Latin American Association of Palliative Care and asked them for referrals to other key informants. In the few cases where those strategies did not suffice, we also sent emails to researchers from major PC institutions and with publications in ACP and/or PC. Similar methods were used by Pastrana et al.[ 8 ] Eligibility criteria Participants were required to be either a representative of the national in-country PC association, or a recognized palliative care expert with five or more years of practice/research in PC and be able to report on the situation of ACP/AD in their countries. Invitations we sent an invitation and the informed consent form by email to each of the key informants that were identified and asked to schedule an online interview with each of them. Data Collection Questionnaire : We developed a questionnaire composed primarily of closed-ended questions for this study ( Supplementary material 2, 3 and 4 ). We attempted to cover the four socio-ecological levels proposed by Risk et al.[ 20 ] and the six pillars of ACP proposed by McMahan et al.[ 21 ] In the questionnaire items, we used a five-point Likert scale ranging from strongly disagree to strongly agree similarly to Finkelstein et al.[ 11 ] Fourteen out of 46 closed-ended questions were supplemented by open-ended questions, where participants were asked to justify their responses. The study questionnaire covered the following areas: characteristics of the key informants, the terminology of ACP/AD, AD regulations, level of education of healthcare professionals on ACP/AD, knowledge and perception of the country’s population on ACP/AD, ACP/AD in the context of clinical decision making at the end of life, barriers, and enablers of ACP/AD. The present report focuses on the first six areas described above. A first draft of the questionnaire was proposed by a geriatrician/palliative care specialist in Brazilian Portuguese [EIOV] and revised by a committee of four researchers (one palliative care specialist [DNF], a geriatrics fellow [NRT], and a family physician [LARB]). The resulting questionnaire was pre-tested by means of online interviews with two palliative care specialists in Brazil. After minor amendments, the questionnaire was translated into Spanish by the first author in collaboration with a native Spanish speaker researcher [MIC]. The Spanish version of the questionnaire was further pre-tested through an interview with a Cuban researcher. Interview We conducted 16 online interviews with 16 key-informants from various countries using the questionnaire described above. All interviews except the one conducted in Brazil, the sole Portuguese-speaking country in the region, were conducted in Spanish. Informants from Peru and Cuba opted to provide their responses in writing. Interviews were performed by two trained researchers [NRT and LARB] involved in the development of the questionnaire. The interviews were recorded to enable the transcription of open-ended responses. In addition, we asked participants to provide us with references to documents (e.g., studies or legal documents) supporting their statements whenever possible. Setting All interviews were conducted online through the Google Meet platform, between July and October 2022. Interviews were video-recorded and transcribed verbatim. Data Analysis: Quantitative data Descriptive analyses of categorical and ordinal variables were performed using absolute numbers and proportions. Continuous variables with approximately normal distribution were reported as means and standard deviation (SD) and, otherwise, as medians and interquartile range (IQR). Statistical analyses were carried out using the R software (version 4.2.2). Qualitative data analysis from transcripts The transcriptions of the data from the open-ended responses where participants explained the reasons for their answers to the 14 closed-ended questions were analyzed as follows. First, a pre-analysis was performed by the first author and a native Spanish speaking researcher from our team to identify the need for further clarifications. Subsequently, we performed member checking [ 22 ] and by asking participants to review the files with their answers to the questionnaire, including the transcripts of their open-ended responses and clarified further questions raised by the research team during the pre-analysis. Second, the transcripts of the open-ended responses were evaluated by two researchers. One of them coded the responses iteratively by comparing their content across participants, looking for differences and similarities, to allow the grouping of similar responses and the identification of specific features that were restricted to the report of a single informant. A second researcher double-checked the categorizations resulting from that process. Whenever further clarifications were needed during that process, we contacted participants again to confirm our interpretations. Analysis of legal/regulatory documents We meticulously examined all regulatory documents related to AD or ACP and any other documents referred to us by the key informants as relevant to these concepts in their respective countries. The process used in these analyses is described in e-Methods, Supplementary material 1. Data triangulation We triangulated the responses of the key informants with the regulatory documents from each country and with research papers identified through our literature review or indicated by the participants. In the few instances where we identified any discrepancies, we contacted the key informants and asked for additional clarifications. Ethical aspects: This study was approved by the Ethics Review Committee of the Botucatu Medical School, São Paulo State University under #57903722.8.0000.5411 on May 5, 2022. The research followed the principles of the Declaration of Helsinki and the Brazilian National Health Council (resolution 466/2012). [ 23 ] RESULTS Of the 20 LA countries, only Haiti, Nicaragua, and Cuba do not have any national PC associations. Thirteen of the existing associations responded to our invitation and appointed a key informant to participate in the study. Following the procedures described in our methods section, we recruited 18 key informants from 18 different LA countries. The only countries that we were unable to recruit key informants from were Nicaragua and Haiti. With the intent of providing some contextual information about LA countries for the interpretation of our findings, we present in Supplementary Material 1 (Figure S1 , Table S1 ) some information about all countries in the region in terms of geographical location, population size, income classification, societal poverty rate, universal health coverage, number of palliative care teams and predominant religion. Key informants’ characteristics All 18 key informants were physicians with expertise in PC and members of recognized PC organizations (associations, societies, or institutions). They had a mean (SD) of 15 (8.6) years working in the field of PC, with a range from 7 to 37 years. Most of them had experience working in both the public and private sectors, including universities. Most provided palliative care to adults and older adults, and only two of them worked specifically with pediatric palliative care (Supplementary Material 1, Table S2 ). Nomenclatures for ACP/AD A range of terms are used to refer to AD and ACP among the different countries in the region, as shown in Table S3 in Supplementary Material 1. In addition, in Mexico AD are referred to by 10 different names across the legislation of different states. According to one of those state laws, AD are called “Premortem Documents”, highlighting a view where those documents are applicable only to direct decisions at the very end of life. AD regulations Only eight LA countries have specific AD regulations: Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, Panama, and Uruguay.[ 24 – 34 ] In total, we evaluated 24 documents (i.e., laws and other types of regulations) from those countries.[ 24 – 33 , 35 – 49 ] In Brazil, the AD regulations do not take the form of laws but of a resolution by its Federal Medical Council, which is the institutional body that regulates medical practice in the country.[ 31 ] In the six other countries, regulations take the form of laws. In Colombia, AD are briefly mentioned in an article of the 2014 federal law “Consuelo Devis Saavedra”, which regulates PC services in the country[ 26 ]and more fully regulated by a 2018 guidance by the Ministry of Health, exclusively dedicated to that subject. In Argentina, AD are mentioned very briefly in an article from the law on “Patients' Rights and their Relationship with Health Professionals and Institutions”.[ 32 ] Similarly, Chilean law mentions advance directives in Article 10 of the regulation on palliative care and the rights of people with terminal or serious illnesses. [ 34 ] Mexico has a federal law (Ley General de Salud) [ 25 ] that mentions the right of autonomy in the context of decision-making, and each state or federal entity can have AD laws that establish specific formats for its registration. In total, 14 states out of a total of 32 states compounding the country have 14 different laws.[ 35 – 46 , 48 , 49 ] Regulatory aspects of ACP/AD practice With the exception of Brazil, Panama, and the State of Coahuila in Mexico, existing regulations bind physicians to follow the directions enclosed within AD. In Brazil, Panama, and the State of Coahuila in Mexico, the available regulations state that physicians must take existing AD into account when making clinical decisions but do not bind them to follow those directions.[ 27 , 31 , 48 ] Panama and Coahuila laws explicitly state that patients’ AD that interfere with good clinical practice can be revoked by physicians. Only in six Mexican states, it is mandatory for AD to be notarized to be valid according to the law.[ 36 , 37 , 40 , 42 , 44 – 47 ] In most other countries, besides notarization there are other possibilities to validly register an AD. Those options include medical records (Brazil, Costa Rica, and eight Mexican states), specific forms produced by the government (Chile, Colombia, Uruguay and nine Mexican states), a free-text document signed by the patient and three witnesses (Panama), and, in Costa Rica, there is also the possibility of making an AD directly at the national registry for that kind of document (Table S4). Specific circumstances where AD come into effect Only in Uruguay and in all Mexican states, AD laws determine that AD are only applicable for situations of terminal illness [ 24 , 34 – 42 , 44 – 49 ] In Argentina, the law mentions AD very briefly and does not specify the circumstances when AD should come into effect. In the remaining five countries where AD regulations exist, AD are intended for situations when the capacity to consent is lost, irrespective of a diagnosis of terminal illness. Who can complete and AD One feature that is specific to most Mexican states AD laws and Colombian AD regulation is that relatives and proxies of patients can make and sign an AD on behalf of terminally ill patients without decision-making capacity. In the other five countries, AD are expected to be completed or communicated by patients themselves. AD Formularies Chile, Colombia, Uruguay, and nine Mexican states have their own AD forms.[ 50 – 57 ] In Colombia, the formulary consists of an official document available on the internet with attached recommendations about its contents and for its proper documentation by the Ministry of Health. There are three specific forms to register an AD depending on whether it will be co-signed by a notary, a physician, or two witnesses. The form consists of a free text document, that specifies procedures that the patient does not want to receive, preferred place-of-death, care preferences concerning families, emotional, and spiritual issues, euthanasia (legally accepted by Ministry of Health), organ donation preferences, and representatives. In Mexico, many of these forms are focused on specifying procedures that patients do not want to receive in case of terminal illness, their representatives, and if organ donation is allowed. In Uruguay, the form contains one closed question about patients’ preferences regarding life-sustaining treatments in the context of incurable terminal illness. The rest of the form consists of free text about patients’ preferences, that should be taken into account during future decision-making processes, and a list of representatives indicated by the patient. Organ Donation In Mexico, the laws state that AD documents must describe the permission (or not) for organ donation. In Colombia, there is a specific question/space in AD forms dedicated to organ donation preferences. In Panama, the law asserts that patients can express their preferences about organ donation in AD documents. In the remaining countries, there is no mention of organ donation in AD regulations or documents. The process to modify or void an AD The process to modify or void an AD varies substantially among countries. In Colombia, Costa Rica, and Mexico the modification process is the same as that used for the creation of an AD. In other words, if the law from those countries requires patients to come to the notary or to a physician to register an AD, then, to modify or void an existing AD demands repeating those procedures (Table 1 ).[ 27 , 30 , 35 – 47 , 49 ] Uruguayan AD law establishes that changes to a previous AD can be made by patients just by verbally informing their physicians, who must then document any changes in medical records.[ 24 ] Interestingly, the informant from El Salvador reported that the inexistence of AD laws makes the process of changing an AD easy, once there is no bureaucratic barrier hindering access to AD documents and documentation. However, it was reported that in El Salvador access to AD and ACP is predominantly restricted to PC services. Key informants from Venezuela and the Dominican Republic stated that, because of the absence of specific regulations, the modification process of an AD is easy and can be made by verbally expressing the desired changes to the doctor. Curiously, the informant from Brazil argued that modifying or voiding an AD in Brazil is easier if patients are cared for in the private than in the public healthcare system given the differential access to physician consultations and palliative care services. Table 1 Legal and practical aspects of Advance Directives regulations in Latin American Countries Country Type of Regulatory Document The process of creating an Advance Directive Are healthcare professionals legally bound to follow the directions enclosed within AD? Circumstances when AD may be put into effect Argentina An article within the Law on the Rights of Patients (2012) and an article within the nation's Civil and Commercial Code Law (2015) The article within the civil and commercial code law does not specify the mandatory presence of legal or health professionals and/or witnesses to create an advance directive document. The 2015 law also no longer demands AD to be notarized, in sharp contrast with the 2012 legislation. Yes The law does not specify the circumstances when AD should come into effect Brazil A resolution by the Federal Medical Council The regulation establishes that physicians must document patients' AD in their medical records and that they must take AD into account when making decisions for patients who have lost the capacity to consent No When patients have lost decision-making capacity Chile An article within the regulation by the Ministry of Health on palliative care and the rights of people with terminal or serious illnesses The regulation requires the presence of the patient, their doctor and the head of the healthcare service where the patient is receiving care. Yes 1 When patients have lost decision-making capacity Colombia An article within the Law Consuelo Devis Saavedra, which regulates PC services in the country, and 2 Resolutions specific to AD from the Ministry of Health The regulations require that for an AD to be valid it must use specific forms developed by the Ministry of Health, and the form used must be signed by either two witnesses, the doctor, or the notary. Yes When patients have lost decision-making capacity - if they are incapacitated or limited in thehir ability to express their preferences of care at the end of life as a consequence of a health event Costa Rica A law specific to AD The AD document can be formalised either through its registration by the notary and two witnesses; by two healthcare professionals in the specialties of medicine, nursing or clinical psychology and two witnesses; or by the representative of the national registry of AD and two witnesses Yes When patients have lost decision-making capacity and a decision regarding medical interventions is required. Mexico (Mex) There is an article of the Federal General Health Law ( Ley General de Salud) about AD and each state or federal entity can have its own AD laws establishing specific regulations Federal District (Mex) Law specific to AD The legislation requires just the notary to register the AD and the use of specific forms developed by the government. In addition, the law establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Águas Calientes (Mex) Law specific to AD The law requires the registration of AD by a notary or documentation by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made. Coahuila (Mex) Law specific to AD The law requires the registration of AD by a notary or documentation by a healthcare professional in the presence of two witnesses Yes Only for terminally ill patients and limited to renouncing medical and surgical treatments considered extraordinary and disproportionate that artificially prolong the life “in a precarious and painful situation of existence, with no possibility of cure”. Colima (Mex) Law specific to AD The law requires the registration of AD by a notary in the presence of two witnesses Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made . Estado do México (Mex) Law specific to AD The law requires the registration of AD by a notary or by a healthcare professional in the presence of two witnesses by using specific forms developed by the government. In addition, the law establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness and when patients have lost decision-making capacity Guanajuato (Mex) Law specific to AD The law requires the registration of AD by a notary or documentation by a healthcare professional in the presence of two witnesses 2 and establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Guerrero (Mex) Law specific to AD The legislation requires the registration of AD by a notary and establishes that relatives can register an AD on behalf of patients without decision-making capacity. Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Hidalgo (Mex) Law specific to AD The law requires the registration of AD by a notary (alone) or by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made. Michoacan (Mex) Law specific to AD The legislation requires the registration of AD by a notary 3 and establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Nayarit (Mex) Law specific to AD The law requires the registration of AD by a notary or by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Oaxaca (Mex) Law specific to AD The law requires the registration of AD by a notary or by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity. Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made. San Luis Potosi (Mex) Law specific to AD The legislation requires just the registration of AD by a notary Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made . Tlaxcala (Mex) Law specific to AD The legislation requires just the registration of AD by a notary Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Yucatán (Mex) Law specific to AD The law requires the registration of AD by a notary in the presence of two witnesses or documentation by a physician in the presence of two witnesses Yes Only in situations of terminal illness, when a decision related to a medical intervention must be made Panamá A chapter/section within the Law on the Rights and Duties of Patients The law requires the registration of AD by a notary or the presence of three witnesses signing the document. No 4 When patients have lost decision-making capacity. Uruguay Law specific to AD The law requires the use of specific forms developed by the Ministry of Health. The form must be signed by the patient and two witnesses or the documentation must be registered by a notary. Yes Only in situations of terminal illness, when a decision related a medical intervention must be made 1 In Chile, the regulations establish that healthcare teams must follow AD unless their content is unlawful (e.g., requests for euthanasia), are in disagreement with existing notions of good clinical practice, or have an experimental nature. 2 Healthcare professionals are allowed to record an Advance Directive only for terminally ill patients. 3 Witnesses are necessary when relatives register Advance Directives on the patient’s behalf 4 The physician must consider the patient's advance directives, but their content is not binding because physicians may decide not to follow the advance directives if they believe that the patient’s requests configure inappropriate clinical practice. AD: Advance Directives, PC: Palliative Care Legal Security All key informants but those from Panama and the Dominican Republic reported that, in general, healthcare professionals do not feel legally secure to perform ACP conversations in their countries. This means that in six of the seven countries with AD regulations and in ten of 11 countries without such regulations, healthcare professionals in general do not feel legally secure about having those conversations. In addition, with regards to feeling legally secure to honor patient’s preferences of care documented in an AD, our data suggests that only in five countries, i.e., Colombia, Chile, Ecuador, Panama, and Uruguay, healthcare professionals in general feel that way. Interestingly, in three of those countries (Chile, Ecuador and Uruguay) the main justification that the informants gave for healthcare professionals feeling secure in respecting AD was not related to any specific AD regulation – indeed, Ecuador does not have any AD regulation – but to the legal recognition of patients’ right to autonomy at large. According to our key informants, the reason for the feeling of legal insecurity by healthcare professionals from countries with existent AD laws is related to poor training not only about ACP but also in PC, and communication skills, as well as the lack of knowledge of AD regulations. Training/education of health professionals in ACP/AD All 18 key informants reported insufficient training of health professionals in ACP/AD and argued that, in general, ACP is rarely taught in undergraduate medical education and its learning is often restricted to specialization courses on PC. Participants often had difficulty to cite specific ACP models that are taught in their countries. Indeed, only informants from Brazil, Costa Rica, Cuba, Ecuador, Mexico, and Venezuela mentioned the use of ACP communication models in the education of healthcare professionals. Informants from Brazil, Ecuador, and Mexico mentioned the SPIKES [ 58 ] protocol as a general communication model that is taught in their countries, while recognizing that it is not specific for ACP discussions. The informants from Costa Rica, Mexico, and Venezuela, stated that the Assertive Communication Model, the Go wish cards ,[ 59 ] and the Grupo de Espiritualidad de la SECPAL (Spanish Palliative Care Society Spirituality Group) questionnaire,[ 60 ] respectively, are taught in those countries as ACP communication models or as communication tools that may be used for that purpose. The informant from Cuba cited a range of theoretical models/frameworks, namely the Health Belief model,[ 61 , 62 ] the PRECEDE model [ 63 , 64 ] and the Stages of Change model [ 65 ] that were adapted to guide ACP education. Knowledge and perception of the population about ACP/AD Knowledge of the population about ACP/AD Only the informants from Uruguay, Peru, and Costa Rica stated that a large part of the population had already heard about ACP/AD, but according to them and all the informants from the 15 remaining countries, most of the population is not aware of the aims of ACP/AD. Relevance attributed by the population to having control over health care decisions Informants from 11 countries (Bolivia, Chile, Colombia, Costa Rica, Cuba, El Salvador, Honduras, Mexico, Panama, the Dominican Republic, and Venezuela) believe that their populations consider it is important to have some control over decisions related to their health care. In Guatemala, a large part of the population has Maya traditions, in which the oldest male of the family, called “varón” , is responsible to make decisions, including in the context of relatives’ illnesses. Because of that, most of the time, ACP discussions are held only between the “varón” and a healthcare professional. Interestingly, in Guatemala religious leaders are commonly consulted by families regarding medical decisions and have a say in their choices regarding end-of-life care. In Ecuador, most of the patients also prefer to delegate their decisions to their relatives. Informants from Argentina and Paraguay stated that the doctor-patient relationships in their countries are based mostly on paternalistic models, and patients often prefer delegating their decisions to their doctors. In Cuba, patients think it is important to have control over decisions related to their healthcare, and the reason reported to explain that attitude is the country’s good degree of health literacy. On the other hand, in Peru, it was described that, due to poor health literacy, a large part of the population does not know about their right to autonomy. Finally, the Brazilian informant argued that the topic of control over healthcare decisions was not within the realm of the population’s imagination. Population's preparation for the end of life Despite a considerable number of LA populations that think it is important to have some control over their healthcare decisions, patients are not prepared for the end of their lives by sharing their preferences of care with healthcare professionals and their families. The only LA country where this appears to occur is Costa Rica, and this was attributed to the long-term integration of PC into their healthcare system. Death was reported as a “taboo" by informants from Argentina, Cuba, Ecuador, Paraguay, Uruguay and Venezuela. Fear of death as a justification for the lack of preparation for the end of life was also reported by informants from Bolivia, Colombia and Venezuela through their responses to our open-ended questions. The informant from Honduras reported that in that country, most of the population knows their end-of-life care preferences but does not have a health professional to talk to about them or guide these conversations. In Brazil, it was reported that the majority of the population does not envision the possibility of preparing for the end of life by sharing information about their preferences of care. The informant from Guatemala stated that the primary reason why most of the country’s population does not prepare for the end of life is closely tied to their very strong religious beliefs. According to these beliefs, God will determine when and how their lives will come to an end. Therefore, preparing for the end of life is almost unthinkable, as they consider it to be exclusively in God’s hands. About the practice of ACP/AD and the decision-making process at the end of life In eight LA countries (Bolivia, Cuba, the Dominican Republic, Ecuador, Guatemala, Honduras, Paraguay and Venezuela) AD documents are described as almost non-existent. Regarding the practice of ACP, the key informant from Paraguay stated that such conversations are exceedingly rare in that country. Characteristics of patients who engage with ACP/AD One important finding was that, according to informants from most countries, in general, ACP conversations happen among more educated ( Fig. 1 . B.) people and those with middle or high income ( Fig. 1 . A.). In addition, informants from 16 countries believed that ACP conversations occur more frequently with patients with specific diseases, being cancer the most cited condition (16 countries) ( Fig. 2 . A.). Contexts where ACP conversations are performed According to our informants, the leading strategy through which patients seek to avoid receiving unwanted treatments at the end of life is through conversations with their families. The second most commonly employed strategy involves joint conversations with their families and a healthcare professional ( Table 2 ). The informants also reported that ACP conversations are performed most commonly by physicians and psychologists ( Fig. 2 . B.) , with patients and relatives together ( Fig. 1 . C.). Cancer overwhelmingly emerged as the clinical condition where ACP conversations take place most frequently ( Fig. 2 . A.). Additionally, the prevailing perception among most informants was that ACP conversations occurred more commonly during the advanced and terminal stages of the disease ( Fig. 1 . D.). Table 2 Strategies adopted by Latin American patients to receive goal-concordant end-of-life care, in order of relevance attributed by the key informants Countries Strategy and Ranking 1st 2nd 3rd 4th 5th 6th Talk with their families Talk with healthcare professionals Talk with healthcare professionals and their families Perform Advance Directives Talk with a lawyer Other 1 Argentina 3rd 1st 2nd 5th 4th Bolivia 1st 2nd Brazil 1st Chile 1st 3rd 2nd 4th Colombia 1st 2nd 4th 3rd Costa Rica 2nd 1st 3rd Cuba 2nd 3rd 1st Ecuador 1st 2nd El Salvador 3rd 1st 2nd 4th Guatemala 1st 4th 2nd 6th 5th 3rd Honduras 1st Mexico 1st 2nd 3rd Panama 1st 3rd 2nd 4th 5th Paraguay 1st 2nd Peru 1st The Dominican Republic 1st 2nd 3rd Uruguay 1st Venezuela 1st 2nd 1 This group included: Religious leaders (mentioned by the key informant from Guatemala and Paraguay), and Social Workers (mentioned by the key informant from Colombia). Key informants could choose multiple strategy options and were asked to list them in order of relevance. Table 3 Informants' degree of agreement regarding the statement: “Patients react positively to Advance Care Planning conversations” Likert scale of agreement N = 17 1 Countries I totally disagree 1 Cuba I disagree 3 Ecuador, Guatemala, Peru I do not agree or disagree 4 Bolívia, Costa Rica, México, Panamá I agree 8 Argentina, Brazil, Chile, Colombia, El Salvador, Dominican Republic, Uruguay 1 The informant from Paraguay preferred not to answer the question, by stating the lack of ACP/AD discussions in the country Informants from Guatemala and Paraguay reported that, when making decisions related to their care at the end of life, people from those countries often seek the advice of religious leaders. These leaders were noted to wield a significant influence on patients’ healthcare decisions, oftentimes even surpassing the influence of healthcare professionals. Patients’ reaction when healthcare professionals start ACP conversations The informants from nine countries (Argentina, Brazil, Chile, Colombia, El Salvador, Dominican Republic, Honduras, Uruguay) believed that, in general, patients respond positively when healthcare professionals initiate ACP conversations ( Table 2 ). In several of these countries, informants stated that when health professionals with adequate training in palliative care initiate such dialogues, patients react positively, as these conversations enable them to share their values and express their doubts surrounding their illness. These informants emphasized that, to a large extent, patients’ reactions to ACP conversations depend on the proficiency of healthcare professionals in conducting those discussions. Notably, there was a consensus among the representatives from all countries about the importance of incorporating patients’ religious/spiritual perspectives during ACP discussions. The informants from Cuba, Ecuador, Guatemala, and Peru shared the perception that, in general, the population from their countries does not react well to healthcare professionals’ attempts to start ACP conversations mostly because of cultural issues, such as the population's fear of death and the hope for a miracle. Healthcare decision-making models Concerning the general process of decision making related to health care[ 66 ] in 10 countries (Argentina, Bolivia, Cuba, Ecuador, El Salvador, Mexico, Panama, Paraguay, Peru, and The Dominican Republic) informants selected paternalism as the most prevalent decision-making model in their countries. The informants from Colombia, and Guatemala believed that the informationist/consumerist decision-making model, in which the role of healthcare professionals is often restricted to providing information so that they patients and/or families make informed decisions, is the most prevalent. In Guatemala, it is the “ varón ” (the family’s oldest male figure) who gives the last word regarding medical decisions, taking precedence over the medical opinions and patients’ preferences. In Peru and Brazil, it is believed that both the paternalistic and informationist/consumerist models coexist as the most prevalent decision-making models. Informants from Chile, Costa Rica, Honduras, Panamá, Uruguay stated that the predominant model in those countries was the mutualistic shared decision-making model. In Venezuela it is believed that both the paternalistic and mutualistic shared decision-making models coexist as the most prevalent decision-making models. The mutualistic shared decision-making model involves the collaboration between patients/families, who contribute their expertise regarding values and preferences, and healthcare professionals, who provide expertise on diseases and treatments. Together, these parties work towards arriving at consensual decisions. Remarkably, the informant from Costa Rica attributed the predominance of the shared decision-making model in that country to the integration of palliative care in their healthcare system. On the other hand, the informant from Venezuela attributed the preponderance of the shared decision-making model to the close doctor-patient relationship characteristic of that country. Representatives’ leeway Informants from seven countries (Argentina, Chile, Costa Rica, El Salvador, Panama, the Dominican Republic, and Venezuela) answered that, when performing ACP conversations, healthcare professionals usually ask the patients how much leeway they would like to give to their families/representatives to make medical decisions on their behalf, including the possibility of modifying their previous decisions. In these countries, ACP conversations take place through a variety of means. Informants from Argentina and El Salvador answered that this occurs because such discussions are performed almost exclusively by palliative care specialists, the identification of representatives and the assessment of the degree of freedom given to them is a common component of ACP. Informants from Venezuela and the Dominican Republic stated that families are usually deeply involved in the care of sick patients and that the close relationship that is established between patients, their families and healthcare professionals facilitates the determination of the amount of leeway that is granted to the family. On the other hand, the informants from eight countries (Bolivia, Brazil, Colombia, Ecuador, Guatemala, Mexico, Peru, and Uruguay) replied that it is uncommon for healthcare professionals to ask about the extent of leeway that patients are willing to grant to their representatives during ACP conversations. According to informants from Bolivia, Brazil, Ecuador, El Salvador, Mexico, Peru, and Uruguay, when ACP conversations take place, they usually do not present this degree of depth because of deficiencies in the education of healthcare professionals in that area. Importantly, the informant from Colombia argued that one of the reasons why that subject is not addressed in ACP conversations is that AD regulations in that country already pose several restrictions against representatives changing the content of an AD. In addition, the informant from Guatemala reported that their culture already strongly favors delegating decisions to the ‘ varón ’ of the family. Consequently, healthcare professionals often assume that patients support that practice. There was substantial heterogeneity in informants’ perspectives about how common it is for patients to grant their families permission to modify their previous choices regarding future treatments. Key informants from five countries (Bolivia, Cuba, Ecuador, Dominican Republic, and Venezuela) described such practice to be common, whereas informants from eight countries (Argentina, Brazil, Colombia, El Salvador, Honduras, Mexico, Panama, Peru, and Uruguay) believed that it was infrequent. ACP/AD in decision making With the exception of Costa Rica, whose informant believed it was not possible to make estimates in that regard, the key informants from all remaining countries answered that it was uncommon for medical records to have a specific field to document AD and/or ACP discussions, and felt that it was also uncommon for AD documents to be present when they are needed to guide decision making. Despite that fact, informants from 13 countries (Argentina, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, the Dominican Republic, Uruguay, and Venezuela) believed that, when AD documents are available, they are useful to guide medical decisions aiming for goal-concordant care. On the other hand, the informant from Brazil argued that AD often are not helpful to guide care within healthcare institutions because of the lack of appropriately trained professionals to manage the care of patients at the end of life. Since AD are virtually non-existent in Bolivia, Cuba, Paraguay, and Peru, our question regarding the utility of AD was not applicable to their context. Eleven key informants (from Brazil, Chile, Costa Rica, Cuba, Ecuador, El Salvador, Honduras, Mexico, Panama, the Dominican Republic and Venezuela) reported that representatives are usually present when a decision concerning life-supporting treatments must be made. In contrast, key informants from only seven countries (Colombia, Cuba, Ecuador, El Salvador, Mexico, the Dominican Republic, and Venezuela) stated that physicians who had performed ACP conversations with patients and their families are usually available when decisions concerning life-supporting treatments must be made. Importantly, informants from all countries, with exception of Honduras and Peru, reported that previous ACP conversations, even in the absence of an AD document, often help the decision-making process at the end of life. All informants, but the one from Brazil, stated that they believed that the promotion of ACP/AD could improve the quality of shared decision-making processes in their countries. Honoring patients’ values and care preferences at the end of life Only eight informants (Argentina, Chile, Colombia, Costa Rica, Cuba, Panama, the Dominican Republic, and Venezuela) agreed that healthcare professionals usually honor patients’ values and care preferences at the end of life. However, Costa Rica was also the only country where its informant strongly agreed that the values and preferences of care of patients were commonly respected at the end of their lives due to the high degree of integration of palliative care into the healthcare system. The informants from Cuba, the Dominican Republic, and Venezuela stated that the main factor contributing to respecting patients’ preferences of care at the end of life is the quality of the longitudinal doctor-patient relationship in those countries. On the other hand, informants from four countries (Brazil, Ecuador, Honduras, and Peru) believed that, in general, the values and preferences of care of patients are not respected at the end of their lives. In Ecuador, Honduras, and Peru the reasons for that were the predominant paternalistic culture of medical decision-making processes, whereas in Brazil and Ecuador this was justified by the scarcity of palliative care professionals, services, and policies. DISCUSSION The concept of ACP/AD emerged in the United States (US) in the second half of the 20th century and has undergone significant changes over time.[ 16 , 21 , 67 , 68 ] In this study, we provide a Latin American perspective about how those concepts were implemented in 18 out of 20 countries from LA. Our results are valuable for offering a cross-cultural angle and providing information about the diversity of experiences around ACP/AD, which enhance the understanding and possibilities for thinking about them, both within and outside of LA. Below we will highlight our most important findings and their implications. Remarkably, Costa Rica was the only country where it was stated that most of the population prepares for the end of life by sharing their preferences of care with healthcare professionals and their families. Costa Rica was also the only country where its informant strongly agreed that the values and preferences of care of patients were commonly respected at the end of their lives. This phenomenon was explained by the longstanding integration of palliative care into their healthcare system,[ 17 ] which is a potent reminder of the fact that ACP does not occur in the vacuum and, for it to be most effective, it must be integrated to a social and healthcare environment of widespread access to palliative care.[ 68 – 71 ] This finding also suggests that integrating palliative care to the healthcare system may foster a cultural change regarding how local populations relate to the end of life, which is a hypothesis consistent with other reports on the history of palliative care in that country. [ 17 ] This makes us question the extent to which the commonly-believed taboo around issues related to death and dying in LA [ 72 – 75 ] is also a result of the historical pattern of healthcare practices and may be amenable to change through interventions in those practices. Another relevant finding concerns the fact that the leading strategy used by patients to avoid receiving certain treatments at the end of life involves talking with their families whereas the secondly ranked strategy was talking with their families together with a healthcare professional. Talking to a lawyer was the least commonly used approach used by patients, whereas making an AD occupied the fourth places in that ranking. Those findings suggest a common preference towards a relational approach to autonomy and decision making that is centered around relationships with families, and which stands in marked opposition to the predominantly legalistic and individualistic framework observed in countries such as the United States [ 16 , 76 – 78 ] That interpretation is supported by other reports from LA countries [ 10 , 70 , 79 – 85 ] as well as our own findings that in some regions (Colombia and Mexico), AD documents could be completed by family members. Importantly, that kind of relational model of autonomy has been recently proposed by several international bioethics researchers as a necessary paradigm shift in that field in response to the failure of the traditional informed consent model that is centered around an individualistic concept of autonomy.[ 86 – 89 ] Hence, the existing relational focus that is characteristic of the culture of most LA countries may offer valuable opportunities and insights for the development of new decolonial approaches to ACP and shared decision making at the end of life. Indeed, the decolonization movement acknowledges that traditional healthcare systems have often been shaped by colonial perspectives, leading to disparities in health outcomes, and seeks to create a more equitable and culturally sensitive healthcare system.[ 90 ] Our findings also indicate that, despite the common preference for a relational model of autonomy, as described earlier, the local regulations concerning AD in most countries with normative frameworks tend to adopt a legalistic pattern heavily influenced by the North American model (e.g., requirements for notarization of AD). In addition, the fact that informants from six out of the seven countries that had some form of regulations in that regard reported that, in general, healthcare professionals do not feel safe from a legal/regulatory perspective to perform ACP/AD suggests that regulations by themselves, and particularly so in settings lacking sufficient education of healthcare professionals and the population around palliative care, are often insufficient to support the implementation of those practices.[ 67 , 79 , 91 , 92 ] Furthermore, our results showed that in countries where healthcare professionals usually establish close and longitudinal relationships with their patients and their families, patient’s preferences of care are commonly respected at the end of life even when no regulations around AD are available, as reported for Cuba, Venezuela, and the Dominican Republic. Those results challenge the belief that AD regulations are essential to promote the respect of patients' wishes at the end of their lives[ 93 – 98 ]That interpretation expands the understanding derived from previous studies in the US, which argued that AD regulations were often “lost in translation” and often ended up representing barriers instead of facilitators to that aim.[ 91 ] We also showed that, despite the existence of similarities between countries, there are also several areas of substantial diversity among them, which highlight the inappropriateness of ‘one-size-fits-all’ approaches. For example, there was substantial variability concerning informants’ beliefs about the relevance attributed by their countries’ populations for exercising control over their healthcare decisions. Other areas of diversity involved, for instance, the extent to which patients’ values and care preferences are honoured at the end of life, and how the population usually reacts to ACP conversations. To the best of our knowledge, only four previous studies [ 10 , 99 – 101 ] reviewed the state of ACP/AD in LA but these studies focused mostly on the regulatory aspects of AD in the region without addressing the process of ACP in detail as in our study. Notably, the most recent of those studies[ 99 , 100 ]shared our interpretation that the existing regulations around AD in LA often are not translated into actual clinical practice. In their review about end-of-life care in LA, Soto-Perez-de-Celis et al. [ 10 ] addressed briefly the cultural aspects related to ACP and concurred with our findings of a preference by the population for relational models of ACP, that integrate the patients’ families into the decision-making processes. Interestingly, another of those studies,[ 101 ] when reviewing the literature about AD in LA, argued in favor of a legalist model based on the US framework as the ideal model to be developed in the region without considering the contextual and cultural specificities of these countries and disregarding the preference for relational models of ACP. In marked contrast, the last of those four studies criticized the existing regulations on AD in LA as having an excessive legalist focus and argued in favor of new regulations centered around the process of ACP and including family members in those conversations and decision-making tasks. Our study has limitations. As previous surveys on PC across countries [ 11 , 12 ] due to time and resource constraints, we were not able to collect data directly from people living with serious illnesses or their families and caregivers. In addition, we used a single expert informant for each country instead of multiple informants. On the other hand, whilst previous surveys relied on online questionnaires completed by two or more informants, we were able to obtain detailed reports through direct interviews with leading experts in palliative care appointed by national PC associations and to triangulate the information provided by them with legal documents and scientific reports, which enhanced our understanding of the region. Despite these limitations, our results have relevant implications for policy and research. First, our findings offer a decolonial standpoint that may promote new ways of thinking about ACP/AD, and which invites healthcare professionals and researchers from other regions of the world to rethink ACP/AD in their countries considering their own contexts and cultures. Second, our findings support the development of ACP models in LA that take the religiousness/spirituality of patients and families into account. Third, our results provide evidence that social inequalities may have been shaping who has access to ACP/AD in LA and highlight the crucial role of addressing these inequities to improve end-of-life care in the region. CONCLUSION In summary, our study provides an overview about the state of ACP/AD in 18 out of 20 Latin American countries. Its results encourage rethinking ACP/AD in the region from a decolonial perspective considering regional characteristics such as the common preference for a relational model of autonomy that includes families in the decision-making process, and the importance of taking the religiousness/spirituality of individuals into account during ACP conversations. Furthermore, our findings indicate that honoring patient’s preferences of care at the end of life requires more than implementing ACP or legislating about AD. It entails integrating palliative care into health care systems, educating healthcare professionals and the population, and fostering longitudinal trusting relationships between those professionals with patients and their families. Lastly, our study sets the stage for future collaborative investigations among Latin American researchers on a series of relevant topics pertaining to this field, such as cross-cultural studies exploring the views of different populations about ACP, the co-development of interventions and the evaluation of new public policies. Abbreviations ACP - Advance Care Planning AD - Advance Directives LA – Latin America PC – Palliative Care US – United States Declarations Ethics approval and consent to participate: This study was approved by the Ethics Review Committee of the Botucatu Medical School, São Paulo State University under #57903722.8.0000.5411 on May 5, 2022. All participants provided written informed consent. Consent for publication: Not Applicable. Availability of data and materials: All results were presented within the manuscript. Competing interests: The authors declare no competing interests. Funding: NRT was supported by a research scholarship grant by the São Paulo Research Foundation (FAPESP) - grant number 2022/14878-7. The funder did not play any role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions: NRT and EIOV designed the study. NRT and LARB performed the interviews. VAT, MGB, DHC, ARN, LRGC, MFS, PB, ATFE, MERAG, TEVC, MOS, NCR, MERR, MEBC, GCP, CFAA, GPA, and IIEG contributed with data and interpretations specific to their countries. NRT and EIOV analyzed the data. NRT, EIOV, FBF, JVDT, LARB, DNF, MICR, RM, ASWP, VAT, MGB, DHC, ARN, LRGC, MFS, PB, ATFE, MERAG, TEVC, MOS, NCR, MERR, MEBC, GCP, CFAA, GPA, and IIEG were involved in the interpretation of findings. NRT and EIOV drafted the first version of the manuscript. 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Int J Environ Res Public Health. 2021;18:1–13. Tripodoro VA, Di Gennaro S, Fila J, Veloso VI, Quiroga C, Varela C, et al. How should Argentina raise Advance Care Planning awareness? Introduction of the Shared Care Planning Group. Z Evid Fortbild Qual Gesundhwes. 2023;180:50–5. Sierra PB, Quintana TR, Aguirre NT. Advance Care Planning in Ecuador. Z Evid Fortbild Qual Gesundhwes. 2023;180:56–8. Kreling B, Selsky C, Perret-Gentil M, Huerta EE, Mandelblatt JS. The worst thing about hospice is that they talk about death’: contrasting hospice decisions and experience among immigrant Central and South American Latinos with US-born White, non-Latino cancer caregivers. Palliat Med. 2010;24:427–34. Gutheil IA, Heyman JC. They Don’t Want to Hear Us. J Soc Work End Life Palliat Care. 2006;2:55–70. Dias LM, Bezerra MR, Barra WF, Carvalho AEV, Castro L, Rego F. Advance care planning and goals of care discussion: the perspectives of Brazilian oncologists. BMC Palliat Care. 2022;21. Thompson GA, Whiffen LH. Can Physicians Demonstrate High Quality Care Using Paternalistic Practices? A Case Study of Paternalism in Latino Physician–Patient Interactions. Qual Health Res. 2018;28:1910–22. Committee on Approaching Death: Addressing Key End of Life Issues; Institute of Medicine (IOM). Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, D.C.: National Academies; 2015. Preston H. Commission on Law & Aging Research: A Tour of State Advance Directive Registries. Bifocal - J Am Bar Association Comm Law Aging. 2016;37:122–7. American Bar Association, Commission on Law and Aging, STATE HEALTH CARE POWER OF ATTORNEY, STATUTES. 2019. https://www.americanbar.org/content/dam/aba/administrative/law_aging/state-health-care-power-of-attorney-statutes.authcheckdam.pdf . Accessed 26 Dec 2023. Rocha Tardelli N, Neves Forte D, de Oliveira Vidal EI. Advance Care Planning in Brazil. Z Evid Fortbild Qual Gesundhwes. 2023. https://doi.org/10.1016/j.zefq.2023.04.010 . Barutta J, Vollmann J. Advance directives in Latin America. An ethical analysis with a focus on Argentina. rev latinoam bioet. 2013;13:80–7. Paiva BSR, Mingardi M, de Almeida LF, de Camargos MG, Valentino TC, de O, Julião M, et al. Go Wish card game—exploring end-of-life wishes of patients in oncology palliative care: a qualitative study. Ann Palliat Med. 2023;0:0–0. Trevizan FB, Paiva CE, Julião M, de Oliveira Valentino TC, Miwa MU, Mingardi M, et al. Comprehension and Decision-Making Capacity Questionnaire About Palliative Care and Advance Care Planning: A Delphi Study. J Palliat Care. 2023;38:41–51. Yennurajalingam S, Parsons HA, Duarte ER, Palma A, Bunge S, Lynn Palmer J, et al. Decisional control preferences of hispanic patients with advanced cancer from the United States and Latin America. J Pain Symptom Manage. 2013;46:376–85. Dittborn M, Turrillas P, Maddocks M, Leniz J. 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BMJ Glob Health. 2020;5:e003394. Castillo LS, Williams BA, Hooper SM, Sabatino CP, Weithorn LA, Sudore RL. Lost in Translation: The Unintended Consequences of Advance Directive Law on Clinical Care. 2011. https://doi.org/10.1059/0003-4819-154-2-201101180-00012 . Fromme EK, Montgomery C, Hickman S. Advance Care Planning in the United States: A 2023 review. Z Evid Fortbild Qual Gesundhwes. 2023;180:59–63. Dadalto L. A necessidade de um modelo de Diretivas Antecipadas de Vontade para o Brasil: estudo comparativo dos modelos português e franceses. Revista M Estudos sobre a morte, os mortos e o morrer. 2019;1:443. Dadalto L. História do Testamento Vital: entendendo o passado e refletindo sobre o presente. Benítez R. Las voluntades anticipadas en Uruguay: reflexiones sobre la Ley 18473. Revista del Instituto de CIencias Juridicas de Puebla. 2015;IX:135–54. Carrasco Gómez A, María Olivares Luna A. González Pedraza Avilés A. Level of knowledge of the Law of Living Will in geriatric population in Mexico. 2019. Ariza Andraca R, Garza Ochoa M, Guzmán Delgado CC. Escamilla Cejudo María de la Soledad, Gaytán Becerril A, Mondragón y Kalb M. La voluntad anticipada. Un dilema ético sustentado en una ley vigente. Med Int Mex. 2008;24:353–6. Moreno EG. Decisiones al final de la vida en México. Entreciencias: Diálogos en la Sociedad del Conocimiento. 2015;3:267–78. Buedo P, Sanchez L, Ojeda MP, della Vedova MN, Labra B, Sipitria R et al. Informed consent and living wills: comparative analysis of the legislation in Latin America. Rev Bioet Derecho. 2023;:25–44. Latorre EC. Advance care planning: An alternative of regulation in Chile, some aspects from comparative law and the ínter American convention on protecting the human rights of older persons. Revista de Derecho Privado. 2020;:201–33. Monteiro R, da SF. Silva Junior AG da. Diretivas antecipadas de vontade: percurso histórico na América Latina. Revista Bioética. 2019;27:86–97. Additional Declarations No competing interests reported. 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(Unicamp)","correspondingAuthor":false,"prefix":"","firstName":"Leonardo","middleName":"de Andrade Rodrigues","lastName":"Brito","suffix":""},{"id":364749871,"identity":"ca63994a-63fe-4650-8665-a11b618d7b25","order_by":26,"name":"Edison Iglesias de Oliveira Vidal","email":"","orcid":"","institution":"São Paulo State University (UNESP)","correspondingAuthor":false,"prefix":"","firstName":"Edison","middleName":"Iglesias de Oliveira","lastName":"Vidal","suffix":""}],"badges":[],"createdAt":"2024-06-03 20:33:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4523931/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4523931/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12904-025-01849-5","type":"published","date":"2025-09-06T15:57:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":75187717,"identity":"58d1b8ba-fcd5-4876-90c8-07366dfeb86c","added_by":"auto","created_at":"2025-01-31 17:58:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3967848,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCharacteristics of patients who engage with Advance Care Planning/Advance Directives and contexts in which Advance Care Planning conversations are usually performed\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003e\u003csup\u003e1\u003c/sup\u003eThe informant from Paraguay reported that conversations take place with people who are close to the patient, not necessarily blood relatives. Informants could choose more than one answer option.\u003c/p\u003e\n\u003cp\u003eACP: Advance Care Planning; AD: Advance Directives.\u003c/p\u003e","description":"","filename":"figures1ad400dpi.png","url":"https://assets-eu.researchsquare.com/files/rs-4523931/v1/768b77a1c1afac74d038c666.png"},{"id":75187715,"identity":"19b0b255-9f4f-4ac0-b0c2-ec530b015184","added_by":"auto","created_at":"2025-01-31 17:58:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1492672,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContexts where Advance Care Planning conversations are usually performed\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegend:\u003c/strong\u003e\u003cem\u003e \u003c/em\u003e\u003csup\u003e1\u003c/sup\u003eThe informants from Guatemala and Paraguay reported that, when making decisions related to their care at the end of life, people from those countries often seek the advice of religious leaders. Informants could choose more than one answer option.\u003c/p\u003e\n\u003cp\u003eACP: Advance Care Planning; AD: Advance Directives.\u003c/p\u003e","description":"","filename":"figure2ab400dpi.png","url":"https://assets-eu.researchsquare.com/files/rs-4523931/v1/aaa9a5ee259c770a4f13e708.png"},{"id":91149344,"identity":"7b838da3-06c8-41d7-bc23-e651cb177cd9","added_by":"auto","created_at":"2025-09-12 06:48:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6577490,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4523931/v1/5c133c33-fe84-48d4-a572-ffc0c56c1e52.pdf"},{"id":75190276,"identity":"01262537-21dd-4f37-b028-6d8d6b1fe41d","added_by":"auto","created_at":"2025-01-31 18:06:27","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":73089,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial224mai24.docx","url":"https://assets-eu.researchsquare.com/files/rs-4523931/v1/748ed92dbf3142ac138420cd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mapping Advance Care Planning and Advance Directives in Latin America","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eThe combination of population ageing and the increase in non-communicable diseases has contributed to a rising global burden of serious health-related suffering, underscoring the need for improved access to palliative care (PC).[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Worldwide, the years lived without good health have increased from 8.6 years to 10 years between 2000 and 2019.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] In 2015, 25\u0026nbsp;million people died experiencing serious health-related suffering, with 80% of these cases occurring in low- and middle-income countries (LMICs).[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn LA, between 1990 and 2019, life expectancy at age 65 increased from 17.1 years to 19.2 whereas increases in healthy life expectancy were much lower (from 12.2 to 13 years).[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The current number of Latinos aged 65 years and older is 56.4\u0026nbsp;million, and it is expected that this number will grow 156% by 2050, reaching 20% of the entire population, with an expected life expectancy of 82 years in 2050.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] LA comprises 20 countries, with most of them being middle-income nations, characterized by limited PC availability compared to high-income countries [\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10 CR11\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Therefore, the expected increase in PC demand is a cause for concern.\u003c/p\u003e \u003cp\u003eA key tenet of PC to reduce the suffering of people living with serious illnesses and their families involves aligning treatments with the values and preferences of care of patients/families. The absence of such alignment poses the risk of medical interventions aimed at decreasing suffering resulting the opposite \u0026ndash; inadvertently increased suffering.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Advance Care Planning (ACP) is considered one of the most important means to achieve that kind of alignment. ACP was defined by an international Delphi consensus as a process that supports adults at any age or stage of health in understanding and sharing their values, life goals, and preferences regarding future medical care.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] Its importance is related to the common scenario where patients approach the end of life, become unable to speak for themselves, and are no longer able to provide informed consent or participate in shared decision-making. Indeed, ACP is considered an important component of PC from the time of diagnosis and continuing through the illness process.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, the concepts of ACP and Advance Directives (AD) were developed primarily in high-income countries[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] from the global North and it is unclear how those concepts have been implemented (or not) in low- and middle-income countries across various regions of the world. Latin American countries exhibit diverse cultural, legal, and socioeconomic characteristics that likely influence the adoption and implementation of ACP/AD in each country (\u003cem\u003eSupplementary Material 1, Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e, Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e\u003c/em\u003e). Despite efforts to assess the state of PC in LA through the Latin American Atlas of Palliative Care,[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] to date, there has been no corresponding initiative to map the state of ACP in this region. As the Atlas played an important role in understanding the strengths, weaknesses and local needs of each Latin American country, we believe that mapping the state of ACP in LA will be instrumental in tailoring ACP interventions to the region\u0026rsquo;s specific characteristics. Furthermore, a recent Delphi study identified ACP/AD as one of the research priorities in PC for LA.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] This research aims to provide an overview of the current state of ACP in LA in terms of regulations, level of education of healthcare professionals on these subjects, knowledge and perception of the country\u0026rsquo;s population on ACP/AD, how those concepts are put into practice, and their use in the context of clinical decision making at the end of life, with the hope that such information can contribute to the progress of ACP and PC in these countries.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis is a cross-sectional survey of ACP/AD in LA using a mixed-methods approach. The reporting followed the Consensus-Based Checklist for Reporting of Survey Studies (CROSS).[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e We searched the internet for all national PC associations in each of the 20 LA countries and sent them invitations by email to participate in this research. We asked each association to appoint a key informant to provide us with information about the state of ACP in their countries. When a country did not have a national PC association, or when that association did not respond to our invitation, we sent emails to researchers who collaborated with the Atlas of Palliative Care in LA [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] members of the Latin American Association of Palliative Care and asked them for referrals to other key informants. In the few cases where those strategies did not suffice, we also sent emails to researchers from major PC institutions and with publications in ACP and/or PC. Similar methods were used by Pastrana et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEligibility criteria\u003c/strong\u003e \u003cp\u003eParticipants were required to be either a representative of the national in-country PC association, or a recognized palliative care expert with five or more years of practice/research in PC and be able to report on the situation of ACP/AD in their countries.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInvitations\u003c/strong\u003e \u003cp\u003e we sent an invitation and the informed consent form by email to each of the key informants that were identified and asked to schedule an online interview with each of them.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003e \u003cem\u003eQuestionnaire\u003c/em\u003e: We developed a questionnaire composed primarily of closed-ended questions for this study (\u003cem\u003eSupplementary material 2, 3 and 4\u003c/em\u003e). We attempted to cover the four socio-ecological levels proposed by Risk et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and the six pillars of ACP proposed by McMahan et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] In the questionnaire items, we used a five-point Likert scale ranging from strongly disagree to strongly agree similarly to Finkelstein et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Fourteen out of 46 closed-ended questions were supplemented by open-ended questions, where participants were asked to justify their responses. The study questionnaire covered the following areas: characteristics of the key informants, the terminology of ACP/AD, AD regulations, level of education of healthcare professionals on ACP/AD, knowledge and perception of the country\u0026rsquo;s population on ACP/AD, ACP/AD in the context of clinical decision making at the end of life, barriers, and enablers of ACP/AD. The present report focuses on the first six areas described above.\u003c/p\u003e \u003cp\u003eA first draft of the questionnaire was proposed by a geriatrician/palliative care specialist in Brazilian Portuguese [EIOV] and revised by a committee of four researchers (one palliative care specialist [DNF], a geriatrics fellow [NRT], and a family physician [LARB]). The resulting questionnaire was pre-tested by means of online interviews with two palliative care specialists in Brazil. After minor amendments, the questionnaire was translated into Spanish by the first author in collaboration with a native Spanish speaker researcher [MIC]. The Spanish version of the questionnaire was further pre-tested through an interview with a Cuban researcher.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInterview\u003c/strong\u003e \u003cp\u003eWe conducted 16 online interviews with 16 key-informants from various countries using the questionnaire described above. All interviews except the one conducted in Brazil, the sole Portuguese-speaking country in the region, were conducted in Spanish. Informants from Peru and Cuba opted to provide their responses in writing. Interviews were performed by two trained researchers [NRT and LARB] involved in the development of the questionnaire. The interviews were recorded to enable the transcription of open-ended responses. In addition, we asked participants to provide us with references to documents (e.g., studies or legal documents) supporting their statements whenever possible.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eAll interviews were conducted online through the Google Meet platform, between July and October 2022. Interviews were video-recorded and transcribed verbatim.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis:\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eQuantitative data\u003c/strong\u003e \u003cp\u003eDescriptive analyses of categorical and ordinal variables were performed using absolute numbers and proportions. Continuous variables with approximately normal distribution were reported as means and standard deviation (SD) and, otherwise, as medians and interquartile range (IQR). Statistical analyses were carried out using the R software (version 4.2.2).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQualitative data analysis from transcripts\u003c/strong\u003e \u003cp\u003eThe transcriptions of the data from the open-ended responses where participants explained the reasons for their answers to the 14 closed-ended questions were analyzed as follows. First, a pre-analysis was performed by the first author and a native Spanish speaking researcher from our team to identify the need for further clarifications. Subsequently, we performed member checking [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and by asking participants to review the files with their answers to the questionnaire, including the transcripts of their open-ended responses and clarified further questions raised by the research team during the pre-analysis. Second, the transcripts of the open-ended responses were evaluated by two researchers. One of them coded the responses iteratively by comparing their content across participants, looking for differences and similarities, to allow the grouping of similar responses and the identification of specific features that were restricted to the report of a single informant. A second researcher double-checked the categorizations resulting from that process. Whenever further clarifications were needed during that process, we contacted participants again to confirm our interpretations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAnalysis of legal/regulatory documents\u003c/strong\u003e \u003cp\u003eWe meticulously examined all regulatory documents related to AD or ACP and any other documents referred to us by the key informants as relevant to these concepts in their respective countries. The process used in these analyses is described in \u003cem\u003ee-Methods, Supplementary material 1.\u003c/em\u003e\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData triangulation\u003c/strong\u003e \u003cp\u003eWe triangulated the responses of the key informants with the regulatory documents from each country and with research papers identified through our literature review or indicated by the participants. In the few instances where we identified any discrepancies, we contacted the key informants and asked for additional clarifications.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical aspects:\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Review Committee of the Botucatu Medical School, S\u0026atilde;o Paulo State University under #57903722.8.0000.5411 on May 5, 2022. The research followed the principles of the Declaration of Helsinki and the Brazilian National Health Council (resolution 466/2012). [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eOf the 20 LA countries, only Haiti, Nicaragua, and Cuba do not have any national PC associations. Thirteen of the existing associations responded to our invitation and appointed a key informant to participate in the study. Following the procedures described in our \u003cspan refid=\"Sec2\" class=\"InternalRef\"\u003emethods\u003c/span\u003e section, we recruited 18 key informants from 18 different LA countries. The only countries that we were unable to recruit key informants from were Nicaragua and Haiti. With the intent of providing some contextual information about LA countries for the interpretation of our findings, we present in \u003cem\u003eSupplementary Material 1 (Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e, Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e)\u003c/em\u003e some information about all countries in the region in terms of geographical location, population size, income classification, societal poverty rate, universal health coverage, number of palliative care teams and predominant religion.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eKey informants\u0026rsquo; characteristics\u003c/h2\u003e \u003cp\u003eAll 18 key informants were physicians with expertise in PC and members of recognized PC organizations (associations, societies, or institutions). They had a mean (SD) of 15 (8.6) years working in the field of PC, with a range from 7 to 37 years. Most of them had experience working in both the public and private sectors, including universities. Most provided palliative care to adults and older adults, and only two of them worked specifically with pediatric palliative care \u003cem\u003e(Supplementary Material 1, Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eNomenclatures for ACP/AD\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA range of terms are used to refer to AD and ACP among the different countries in the region, as shown in Table S3 in Supplementary Material 1. In addition, in Mexico AD are referred to by 10 different names across the legislation of different states. According to one of those state laws, AD are called \u0026ldquo;Premortem Documents\u0026rdquo;, highlighting a view where those documents are applicable only to direct decisions at the very end of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eAD regulations\u003c/h2\u003e \u003cp\u003eOnly eight LA countries have specific AD regulations: Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, Panama, and Uruguay.[\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] In total, we evaluated 24 documents (i.e., laws and other types of regulations) from those countries.[\u003cspan additionalcitationids=\"CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46 CR47 CR48\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn Brazil, the AD regulations do not take the form of laws but of a resolution by its Federal Medical Council, which is the institutional body that regulates medical practice in the country.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] In the six other countries, regulations take the form of laws. In Colombia, AD are briefly mentioned in an article of the 2014 federal law \u0026ldquo;Consuelo Devis Saavedra\u0026rdquo;, which regulates PC services in the country[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]and more fully regulated by a 2018 guidance by the Ministry of Health, exclusively dedicated to that subject. In Argentina, AD are mentioned very briefly in an article from the law on \u0026ldquo;Patients' Rights and their Relationship with Health Professionals and Institutions\u0026rdquo;.[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] Similarly, Chilean law mentions advance directives in Article 10 of the regulation on palliative care and the rights of people with terminal or serious illnesses. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] Mexico has a federal law (Ley General de Salud) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] that mentions the right of autonomy in the context of decision-making, and each state or federal entity can have AD laws that establish specific formats for its registration. In total, 14 states out of a total of 32 states compounding the country have 14 different laws.[\u003cspan additionalcitationids=\"CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRegulatory aspects of ACP/AD practice\u003c/h2\u003e \u003cp\u003eWith the exception of Brazil, Panama, and the State of Coahuila in Mexico, existing regulations bind physicians to follow the directions enclosed within AD. In Brazil, Panama, and the State of Coahuila in Mexico, the available regulations state that physicians must take existing AD into account when making clinical decisions but do not bind them to follow those directions.[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] Panama and Coahuila laws explicitly state that patients\u0026rsquo; AD that interfere with good clinical practice can be revoked by physicians.\u003c/p\u003e \u003cp\u003eOnly in six Mexican states, it is mandatory for AD to be notarized to be valid according to the law.[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] In most other countries, besides notarization there are other possibilities to validly register an AD. Those options include medical records (Brazil, Costa Rica, and eight Mexican states), specific forms produced by the government (Chile, Colombia, Uruguay and nine Mexican states), a free-text document signed by the patient and three witnesses (Panama), and, in Costa Rica, there is also the possibility of making an AD directly at the national registry for that kind of document (Table S4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSpecific circumstances where AD come into effect\u003c/h2\u003e \u003cp\u003eOnly in Uruguay and in all Mexican states, AD laws determine that AD are only applicable for situations of terminal illness [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37 CR38 CR39 CR40 CR41\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45 CR46 CR47 CR48\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] In Argentina, the law mentions AD very briefly and does not specify the circumstances when AD should come into effect. In the remaining five countries where AD regulations exist, AD are intended for situations when the capacity to consent is lost, irrespective of a diagnosis of terminal illness.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eWho can complete and AD\u003c/h2\u003e \u003cp\u003eOne feature that is specific to most Mexican states AD laws and Colombian AD regulation is that relatives and proxies of patients can make and sign an AD on behalf of terminally ill patients without decision-making capacity. In the other five countries, AD are expected to be completed or communicated by patients themselves.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAD Formularies\u003c/h2\u003e \u003cp\u003eChile, Colombia, Uruguay, and nine Mexican states have their own AD forms.[\u003cspan additionalcitationids=\"CR51 CR52 CR53 CR54 CR55 CR56\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] In Colombia, the formulary consists of an official document available on the internet with attached recommendations about its contents and for its proper documentation by the Ministry of Health. There are three specific forms to register an AD depending on whether it will be co-signed by a notary, a physician, or two witnesses. The form consists of a free text document, that specifies procedures that the patient does not want to receive, preferred place-of-death, care preferences concerning families, emotional, and spiritual issues, euthanasia (legally accepted by Ministry of Health), organ donation preferences, and representatives. In Mexico, many of these forms are focused on specifying procedures that patients do not want to receive in case of terminal illness, their representatives, and if organ donation is allowed. In Uruguay, the form contains one closed question about patients\u0026rsquo; preferences regarding life-sustaining treatments in the context of incurable terminal illness. The rest of the form consists of free text about patients\u0026rsquo; preferences, that should be taken into account during future decision-making processes, and a list of representatives indicated by the patient.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eOrgan Donation\u003c/h2\u003e \u003cp\u003eIn Mexico, the laws state that AD documents must describe the permission (or not) for organ donation. In Colombia, there is a specific question/space in AD forms dedicated to organ donation preferences. In Panama, the law asserts that patients can express their preferences about organ donation in AD documents. In the remaining countries, there is no mention of organ donation in AD regulations or documents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eThe process to modify or void an AD\u003c/h2\u003e \u003cp\u003eThe process to modify or void an AD varies substantially among countries. In Colombia, Costa Rica, and Mexico the modification process is the same as that used for the creation of an AD. In other words, if the law from those countries requires patients to come to the notary or to a physician to register an AD, then, to modify or void an existing AD demands repeating those procedures (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan additionalcitationids=\"CR36 CR37 CR38 CR39 CR40 CR41 CR42 CR43 CR44 CR45 CR46\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] Uruguayan AD law establishes that changes to a previous AD can be made by patients just by verbally informing their physicians, who must then document any changes in medical records.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Interestingly, the informant from El Salvador reported that the inexistence of AD laws makes the process of changing an AD easy, once there is no bureaucratic barrier hindering access to AD documents and documentation. However, it was reported that in El Salvador access to AD and ACP is predominantly restricted to PC services. Key informants from Venezuela and the Dominican Republic stated that, because of the absence of specific regulations, the modification process of an AD is easy and can be made by verbally expressing the desired changes to the doctor. Curiously, the informant from Brazil argued that modifying or voiding an AD in Brazil is easier if patients are cared for in the private than in the public healthcare system given the differential access to physician consultations and palliative care services.\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\u003eLegal and practical aspects of Advance Directives regulations in Latin American Countries\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of Regulatory Document\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe process of creating an Advance Directive\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAre healthcare professionals legally bound to follow the directions enclosed within AD?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCircumstances when AD may be put into effect\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArgentina\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn article within the Law on the Rights of Patients (2012) and an article within the nation's Civil and Commercial Code Law (2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe article within the civil and commercial code law does not specify the mandatory presence of legal or health professionals and/or witnesses to create an advance directive document. The 2015 law also no longer demands AD to be notarized, in sharp contrast with the 2012 legislation.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe law does not specify the circumstances when AD should come into effect\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBrazil\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA resolution by the Federal Medical Council\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe regulation establishes that physicians must document patients' AD in their medical records and that they must take AD into account when making decisions for patients who have lost the capacity to consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhen patients have lost decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChile\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn article within the regulation by the Ministry of Health on palliative care and the rights of people with terminal or serious illnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe regulation requires the presence of the patient, their doctor and the head of the healthcare service where the patient is receiving care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhen patients have lost decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColombia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAn article within the Law Consuelo Devis Saavedra, which regulates PC services in the country, and 2 Resolutions specific to AD from the Ministry of Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe regulations require that for an AD to be valid it must use specific forms developed by the Ministry of Health, and the form used must be signed by either two witnesses, the doctor, or the notary.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhen patients have lost decision-making capacity - if they are incapacitated or limited in thehir ability to express their preferences of care at the end of life as a consequence of a health event\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCosta Rica\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA law specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe AD document can be formalised either through its registration by the notary and two witnesses; by two healthcare professionals in the specialties of medicine, nursing or clinical psychology and two witnesses; or by the representative of the national registry of AD and two witnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhen patients have lost decision-making capacity and a decision regarding medical interventions is required.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMexico (Mex)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere is an article of the Federal General Health Law (\u003cem\u003eLey General de Salud)\u003c/em\u003e about AD and each state or federal entity can have its own AD laws establishing specific regulations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFederal District (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe legislation requires just the notary to register the AD and the use of specific forms developed by the government. In addition, the law establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003e\u0026Aacute;guas Calientes (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or documentation by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCoahuila (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or documentation by a healthcare professional in the presence of two witnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly for terminally ill patients and limited to renouncing medical and surgical treatments considered\u003c/p\u003e \u003cp\u003eextraordinary and disproportionate that artificially prolong the life \u0026ldquo;in a precarious and painful situation of existence, with no possibility of cure\u0026rdquo;.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eColima (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary in the presence of two witnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEstado do M\u0026eacute;xico (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or by a healthcare professional in the presence of two witnesses by using specific forms developed by the government. In addition, the law establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness and when patients have lost decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGuanajuato (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or documentation by a healthcare professional in the presence of two witnesses\u003csup\u003e2\u003c/sup\u003e and establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eGuerrero (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe legislation requires the registration of AD by a notary and establishes that relatives can register an AD on behalf of patients without decision-making capacity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHidalgo (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary (alone) or by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMichoacan (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe legislation requires the registration of AD by a notary\u003csup\u003e3\u003c/sup\u003e and establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNayarit (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOaxaca (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or by a healthcare professional in the presence of two witnesses and establishes that relatives can register AD on behalf of patients without decision-making capacity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSan Luis Potosi (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe legislation requires just the registration of AD by a notary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003cp\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTlaxcala (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe legislation requires just the registration of AD by a notary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYucat\u0026aacute;n (Mex)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary in the presence of two witnesses or documentation by a physician in the presence of two witnesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related to a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePanam\u0026aacute;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA chapter/section within the Law on the Rights and Duties of Patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the registration of AD by a notary or the presence of three witnesses signing the document.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWhen patients have lost decision-making capacity.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUruguay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaw specific to AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe law requires the use of specific forms developed by the Ministry of Health. The form must be signed by the patient and two witnesses or the documentation must be registered by a notary.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOnly in situations of terminal illness, when a decision related a medical intervention must be made\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e1\u003c/sup\u003e In Chile, the regulations establish that healthcare teams must follow AD unless their content is unlawful (e.g., requests for euthanasia), are in disagreement with existing notions of good clinical practice, or have an experimental nature.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e2\u003c/sup\u003e Healthcare professionals are allowed to record an Advance Directive only for terminally ill patients.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e3\u003c/sup\u003e Witnesses are necessary when relatives register Advance Directives on the patient\u0026rsquo;s behalf\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e4\u003c/sup\u003e The physician must consider the patient's advance directives, but their content is not binding because physicians may decide not to follow the advance directives if they believe that the patient\u0026rsquo;s requests configure inappropriate clinical practice.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eAD: Advance Directives, PC: Palliative Care\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLegal Security\u003c/h2\u003e \u003cp\u003eAll key informants but those from Panama and the Dominican Republic reported that, in general, healthcare professionals do not feel legally secure to perform ACP conversations in their countries. This means that in six of the seven countries with AD regulations and in ten of 11 countries without such regulations, healthcare professionals in general do not feel legally secure about having those conversations.\u003c/p\u003e \u003cp\u003eIn addition, with regards to feeling legally secure to honor patient\u0026rsquo;s preferences of care documented in an AD, our data suggests that only in five countries, i.e., Colombia, Chile, Ecuador, Panama, and Uruguay, healthcare professionals in general feel that way. Interestingly, in three of those countries (Chile, Ecuador and Uruguay) the main justification that the informants gave for healthcare professionals feeling secure in respecting AD was not related to any specific AD regulation \u0026ndash; indeed, Ecuador does not have any AD regulation \u0026ndash; but to the legal recognition of patients\u0026rsquo; right to autonomy at large. According to our key informants, the reason for the feeling of legal insecurity by healthcare professionals from countries with existent AD laws is related to poor training not only about ACP but also in PC, and communication skills, as well as the lack of knowledge of AD regulations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eTraining/education of health professionals in ACP/AD\u003c/h2\u003e \u003cp\u003eAll 18 key informants reported insufficient training of health professionals in ACP/AD and argued that, in general, ACP is rarely taught in undergraduate medical education and its learning is often restricted to specialization courses on PC. Participants often had difficulty to cite specific ACP models that are taught in their countries. Indeed, only informants from Brazil, Costa Rica, Cuba, Ecuador, Mexico, and Venezuela mentioned the use of ACP communication models in the education of healthcare professionals. Informants from Brazil, Ecuador, and Mexico mentioned the SPIKES [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e] protocol as a general communication model that is taught in their countries, while recognizing that it is not specific for ACP discussions. The informants from Costa Rica, Mexico, and Venezuela, stated that the Assertive Communication Model, the \u003cem\u003eGo wish cards\u003c/em\u003e,[\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] and the \u003cem\u003eGrupo de Espiritualidad de la SECPAL\u003c/em\u003e (Spanish Palliative Care Society Spirituality Group) questionnaire,[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e] respectively, are taught in those countries as ACP communication models or as communication tools that may be used for that purpose. The informant from Cuba cited a range of theoretical models/frameworks, namely the Health Belief model,[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] the PRECEDE model [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e] and the Stages of Change model [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e] that were adapted to guide ACP education.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and perception of the population about ACP/AD\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eKnowledge of the population about ACP/AD\u003c/h2\u003e \u003cp\u003eOnly the informants from Uruguay, Peru, and Costa Rica stated that a large part of the population had already heard about ACP/AD, but according to them and all the informants from the 15 remaining countries, most of the population is not aware of the aims of ACP/AD.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eRelevance attributed by the population to having control over health care decisions\u003c/h2\u003e \u003cp\u003eInformants from 11 countries (Bolivia, Chile, Colombia, Costa Rica, Cuba, El Salvador, Honduras, Mexico, Panama, the Dominican Republic, and Venezuela) believe that their populations consider it is important to have some control over decisions related to their health care. In Guatemala, a large part of the population has Maya traditions, in which the oldest male of the family, called \u003cem\u003e\u0026ldquo;var\u0026oacute;n\u0026rdquo;\u003c/em\u003e, is responsible to make decisions, including in the context of relatives\u0026rsquo; illnesses. Because of that, most of the time, ACP discussions are held only between the \u003cem\u003e\u0026ldquo;var\u0026oacute;n\u0026rdquo;\u003c/em\u003e and a healthcare professional. Interestingly, in Guatemala religious leaders are commonly consulted by families regarding medical decisions and have a say in their choices regarding end-of-life care. In Ecuador, most of the patients also prefer to delegate their decisions to their relatives. Informants from Argentina and Paraguay stated that the doctor-patient relationships in their countries are based mostly on paternalistic models, and patients often prefer delegating their decisions to their doctors. In Cuba, patients think it is important to have control over decisions related to their healthcare, and the reason reported to explain that attitude is the country\u0026rsquo;s good degree of health literacy. On the other hand, in Peru, it was described that, due to poor health literacy, a large part of the population does not know about their right to autonomy. Finally, the Brazilian informant argued that the topic of control over healthcare decisions was not within the realm of the population\u0026rsquo;s imagination.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ePopulation's preparation for the end of life\u003c/h2\u003e \u003cp\u003eDespite a considerable number of LA populations that think it is important to have some control over their healthcare decisions, patients are not prepared for the end of their lives by sharing their preferences of care with healthcare professionals and their families. The only LA country where this appears to occur is Costa Rica, and this was attributed to the long-term integration of PC into their healthcare system. Death was reported as a \u0026ldquo;taboo\" by informants from Argentina, Cuba, Ecuador, Paraguay, Uruguay and Venezuela. Fear of death as a justification for the lack of preparation for the end of life was also reported by informants from Bolivia, Colombia and Venezuela through their responses to our open-ended questions. The informant from Honduras reported that in that country, most of the population knows their end-of-life care preferences but does not have a health professional to talk to about them or guide these conversations. In Brazil, it was reported that the majority of the population does not envision the possibility of preparing for the end of life by sharing information about their preferences of care. The informant from Guatemala stated that the primary reason why most of the country\u0026rsquo;s population does not prepare for the end of life is closely tied to their very strong religious beliefs. According to these beliefs, God will determine when and how their lives will come to an end. Therefore, preparing for the end of life is almost unthinkable, as they consider it to be exclusively in God\u0026rsquo;s hands.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eAbout the practice of ACP/AD and the decision-making process at the end of life\u003c/h2\u003e \u003cp\u003eIn eight LA countries (Bolivia, Cuba, the Dominican Republic, Ecuador, Guatemala, Honduras, Paraguay and Venezuela) AD documents are described as almost non-existent. Regarding the practice of ACP, the key informant from Paraguay stated that such conversations are exceedingly rare in that country.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eCharacteristics of patients who engage with ACP/AD\u003c/h2\u003e \u003cp\u003eOne important finding was that, according to informants from most countries, in general, ACP conversations happen among more educated \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003cem\u003eB.)\u003c/em\u003e people and those with middle or high income \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003cem\u003eA.).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition, informants from 16 countries believed that ACP conversations occur more frequently with patients with specific diseases, being cancer the most cited condition (16 countries) \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003cem\u003eA.).\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eContexts where ACP conversations are performed\u003c/h2\u003e \u003cp\u003eAccording to our informants, the leading strategy through which patients seek to avoid receiving unwanted treatments at the end of life is through conversations with their families. The second most commonly employed strategy involves joint conversations with their families and a healthcare professional \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e).\u003c/em\u003e The informants also reported that ACP conversations are performed most commonly by physicians and psychologists \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003cem\u003eB.)\u003c/em\u003e, with patients and relatives together \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003cem\u003eC.).\u003c/em\u003e Cancer overwhelmingly emerged as the clinical condition where ACP conversations take place most frequently \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003cem\u003eA.).\u003c/em\u003e Additionally, the prevailing perception among most informants was that ACP conversations occurred more commonly during the advanced and terminal stages of the disease \u003cem\u003e(\u003c/em\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003cem\u003eD.).\u003c/em\u003e\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\u003eStrategies adopted by Latin American patients to receive goal-concordant end-of-life care, in order of relevance attributed by the key informants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\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 \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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCountries\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eStrategy and Ranking\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e6th\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTalk with their families\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTalk with healthcare professionals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTalk with healthcare professionals and their families\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePerform Advance Directives\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTalk with a lawyer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eOther\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eArgentina\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBolivia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBrazil\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChile\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eColombia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCosta Rica\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCuba\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEcuador\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEl Salvador\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGuatemala\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHonduras\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMexico\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePanama\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5th\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParaguay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePeru\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThe Dominican Republic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3rd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUruguay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c9\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVenezuela\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2nd\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003csup\u003e1\u003c/sup\u003eThis group included: Religious leaders (mentioned by the key informant from Guatemala and Paraguay), and Social Workers (mentioned by the key informant from Colombia). Key informants could choose multiple strategy options and were asked to list them in order of relevance.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \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\u003eInformants' degree of agreement regarding the statement: \u0026ldquo;Patients react positively to Advance Care Planning conversations\u0026rdquo;\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\u003eLikert scale of agreement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;17\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCountries\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI totally disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCuba\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEcuador, Guatemala, Peru\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI do not agree or disagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBol\u0026iacute;via, Costa Rica, M\u0026eacute;xico, Panam\u0026aacute;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI agree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eArgentina, Brazil, Chile, Colombia, El Salvador, Dominican Republic, Uruguay\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003e1\u003c/sup\u003e \u003cem\u003eThe informant from Paraguay preferred not to answer the question, by stating the lack of ACP/AD discussions in the country\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eInformants from Guatemala and Paraguay reported that, when making decisions related to their care at the end of life, people from those countries often seek the advice of religious leaders. These leaders were noted to wield a significant influence on patients\u0026rsquo; healthcare decisions, oftentimes even surpassing the influence of healthcare professionals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePatients\u0026rsquo; reaction when healthcare professionals start ACP conversations\u003c/h2\u003e \u003cp\u003eThe informants from nine countries (Argentina, Brazil, Chile, Colombia, El Salvador, Dominican Republic, Honduras, Uruguay) believed that, in general, patients respond positively when healthcare professionals initiate ACP conversations \u003cem\u003e(\u003c/em\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cem\u003e).\u003c/em\u003e In several of these countries, informants stated that when health professionals with adequate training in palliative care initiate such dialogues, patients react positively, as these conversations enable them to share their values and express their doubts surrounding their illness. These informants emphasized that, to a large extent, patients\u0026rsquo; reactions to ACP conversations depend on the proficiency of healthcare professionals in conducting those discussions. Notably, there was a consensus among the representatives from all countries about the importance of incorporating patients\u0026rsquo; religious/spiritual perspectives during ACP discussions.\u003c/p\u003e \u003cp\u003eThe informants from Cuba, Ecuador, Guatemala, and Peru shared the perception that, in general, the population from their countries does not react well to healthcare professionals\u0026rsquo; attempts to start ACP conversations mostly because of cultural issues, such as the population's fear of death and the hope for a miracle.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare decision-making models\u003c/h2\u003e \u003cp\u003eConcerning the general process of decision making related to health care[\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e] in 10 countries (Argentina, Bolivia, Cuba, Ecuador, El Salvador, Mexico, Panama, Paraguay, Peru, and The Dominican Republic) informants selected paternalism as the most prevalent decision-making model in their countries. The informants from Colombia, and Guatemala believed that the informationist/consumerist decision-making model, in which the role of healthcare professionals is often restricted to providing information so that they patients and/or families make informed decisions, is the most prevalent. In Guatemala, it is the \u0026ldquo;\u003cem\u003evar\u0026oacute;n\u003c/em\u003e\u0026rdquo; (the family\u0026rsquo;s oldest male figure) who gives the last word regarding medical decisions, taking precedence over the medical opinions and patients\u0026rsquo; preferences. In Peru and Brazil, it is believed that both the paternalistic and informationist/consumerist models coexist as the most prevalent decision-making models.\u003c/p\u003e \u003cp\u003eInformants from Chile, Costa Rica, Honduras, Panam\u0026aacute;, Uruguay stated that the predominant model in those countries was the mutualistic shared decision-making model. In Venezuela it is believed that both the paternalistic and mutualistic shared decision-making models coexist as the most prevalent decision-making models. The mutualistic shared decision-making model involves the collaboration between patients/families, who contribute their expertise regarding values and preferences, and healthcare professionals, who provide expertise on diseases and treatments. Together, these parties work towards arriving at consensual decisions.\u003c/p\u003e \u003cp\u003eRemarkably, the informant from Costa Rica attributed the predominance of the shared decision-making model in that country to the integration of palliative care in their healthcare system. On the other hand, the informant from Venezuela attributed the preponderance of the shared decision-making model to the close doctor-patient relationship characteristic of that country.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eRepresentatives\u0026rsquo; leeway\u003c/h2\u003e \u003cp\u003eInformants from seven countries (Argentina, Chile, Costa Rica, El Salvador, Panama, the Dominican Republic, and Venezuela) answered that, when performing ACP conversations, healthcare professionals usually ask the patients how much leeway they would like to give to their families/representatives to make medical decisions on their behalf, including the possibility of modifying their previous decisions. In these countries, ACP conversations take place through a variety of means. Informants from Argentina and El Salvador answered that this occurs because such discussions are performed almost exclusively by palliative care specialists, the identification of representatives and the assessment of the degree of freedom given to them is a common component of ACP. Informants from Venezuela and the Dominican Republic stated that families are usually deeply involved in the care of sick patients and that the close relationship that is established between patients, their families and healthcare professionals facilitates the determination of the amount of leeway that is granted to the family.\u003c/p\u003e \u003cp\u003eOn the other hand, the informants from eight countries (Bolivia, Brazil, Colombia, Ecuador, Guatemala, Mexico, Peru, and Uruguay) replied that it is uncommon for healthcare professionals to ask about the extent of leeway that patients are willing to grant to their representatives during ACP conversations. According to informants from Bolivia, Brazil, Ecuador, El Salvador, Mexico, Peru, and Uruguay, when ACP conversations take place, they usually do not present this degree of depth because of deficiencies in the education of healthcare professionals in that area. Importantly, the informant from Colombia argued that one of the reasons why that subject is not addressed in ACP conversations is that AD regulations in that country already pose several restrictions against representatives changing the content of an AD. In addition, the informant from Guatemala reported that their culture already strongly favors delegating decisions to the \u0026lsquo;\u003cem\u003evar\u0026oacute;n\u003c/em\u003e\u0026rsquo; of the family. Consequently, healthcare professionals often assume that patients support that practice.\u003c/p\u003e \u003cp\u003eThere was substantial heterogeneity in informants\u0026rsquo; perspectives about how common it is for patients to grant their families permission to modify their previous choices regarding future treatments. Key informants from five countries (Bolivia, Cuba, Ecuador, Dominican Republic, and Venezuela) described such practice to be common, whereas informants from eight countries (Argentina, Brazil, Colombia, El Salvador, Honduras, Mexico, Panama, Peru, and Uruguay) believed that it was infrequent.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eACP/AD in decision making\u003c/h3\u003e\n\u003cp\u003eWith the exception of Costa Rica, whose informant believed it was not possible to make estimates in that regard, the key informants from all remaining countries answered that it was uncommon for medical records to have a specific field to document AD and/or ACP discussions, and felt that it was also uncommon for AD documents to be present when they are needed to guide decision making. Despite that fact, informants from 13 countries (Argentina, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Panama, the Dominican Republic, Uruguay, and Venezuela) believed that, when AD documents are available, they are useful to guide medical decisions aiming for goal-concordant care.\u003c/p\u003e \u003cp\u003eOn the other hand, the informant from Brazil argued that AD often are not helpful to guide care within healthcare institutions because of the lack of appropriately trained professionals to manage the care of patients at the end of life. Since AD are virtually non-existent in Bolivia, Cuba, Paraguay, and Peru, our question regarding the utility of AD was not applicable to their context.\u003c/p\u003e \u003cp\u003eEleven key informants (from Brazil, Chile, Costa Rica, Cuba, Ecuador, El Salvador, Honduras, Mexico, Panama, the Dominican Republic and Venezuela) reported that representatives are usually present when a decision concerning life-supporting treatments must be made. In contrast, key informants from only seven countries (Colombia, Cuba, Ecuador, El Salvador, Mexico, the Dominican Republic, and Venezuela) stated that physicians who had performed ACP conversations with patients and their families are usually available when decisions concerning life-supporting treatments must be made.\u003c/p\u003e \u003cp\u003eImportantly, informants from all countries, with exception of Honduras and Peru, reported that previous ACP conversations, even in the absence of an AD document, often help the decision-making process at the end of life. All informants, but the one from Brazil, stated that they believed that the promotion of ACP/AD could improve the quality of shared decision-making processes in their countries.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eHonoring patients\u0026rsquo; values and care preferences at the end of life\u003c/h2\u003e \u003cp\u003eOnly eight informants (Argentina, Chile, Colombia, Costa Rica, Cuba, Panama, the Dominican Republic, and Venezuela) agreed that healthcare professionals usually honor patients\u0026rsquo; values and care preferences at the end of life. However, Costa Rica was also the only country where its informant strongly agreed that the values and preferences of care of patients were commonly respected at the end of their lives due to the high degree of integration of palliative care into the healthcare system. The informants from Cuba, the Dominican Republic, and Venezuela stated that the main factor contributing to respecting patients\u0026rsquo; preferences of care at the end of life is the quality of the longitudinal doctor-patient relationship in those countries. On the other hand, informants from four countries (Brazil, Ecuador, Honduras, and Peru) believed that, in general, the values and preferences of care of patients are not respected at the end of their lives. In Ecuador, Honduras, and Peru the reasons for that were the predominant paternalistic culture of medical decision-making processes, whereas in Brazil and Ecuador this was justified by the scarcity of palliative care professionals, services, and policies.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe concept of ACP/AD emerged in the United States (US) in the second half of the 20th century and has undergone significant changes over time.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e] In this study, we provide a Latin American perspective about how those concepts were implemented in 18 out of 20 countries from LA. Our results are valuable for offering a cross-cultural angle and providing information about the diversity of experiences around ACP/AD, which enhance the understanding and possibilities for thinking about them, both within and outside of LA. Below we will highlight our most important findings and their implications.\u003c/p\u003e \u003cp\u003eRemarkably, Costa Rica was the only country where it was stated that most of the population prepares for the end of life by sharing their preferences of care with healthcare professionals and their families. Costa Rica was also the only country where its informant strongly agreed that the values and preferences of care of patients were commonly respected at the end of their lives. This phenomenon was explained by the longstanding integration of palliative care into their healthcare system,[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] which is a potent reminder of the fact that ACP does not occur in the vacuum and, for it to be most effective, it must be integrated to a social and healthcare environment of widespread access to palliative care.[\u003cspan additionalcitationids=\"CR69 CR70\" citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e] This finding also suggests that integrating palliative care to the healthcare system may foster a cultural change regarding how local populations relate to the end of life, which is a hypothesis consistent with other reports on the history of palliative care in that country. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] This makes us question the extent to which the commonly-believed taboo around issues related to death and dying in LA [\u003cspan additionalcitationids=\"CR73 CR74\" citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e] is also a result of the historical pattern of healthcare practices and may be amenable to change through interventions in those practices.\u003c/p\u003e \u003cp\u003eAnother relevant finding concerns the fact that the leading strategy used by patients to avoid receiving certain treatments at the end of life involves talking with their families whereas the secondly ranked strategy was talking with their families together with a healthcare professional. Talking to a lawyer was the least commonly used approach used by patients, whereas making an AD occupied the fourth places in that ranking. Those findings suggest a common preference towards a relational approach to autonomy and decision making that is centered around relationships with families, and which stands in marked opposition to the predominantly legalistic and individualistic framework observed in countries such as the United States [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR77\" citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e] That interpretation is supported by other reports from LA countries [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan additionalcitationids=\"CR80 CR81 CR82 CR83 CR84\" citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e85\u003c/span\u003e] as well as our own findings that in some regions (Colombia and Mexico), AD documents could be completed by family members. Importantly, that kind of relational model of autonomy has been recently proposed by several international bioethics researchers as a necessary paradigm shift in that field in response to the failure of the traditional informed consent model that is centered around an individualistic concept of autonomy.[\u003cspan additionalcitationids=\"CR87 CR88\" citationid=\"CR86\" class=\"CitationRef\"\u003e86\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e89\u003c/span\u003e] Hence, the existing relational focus that is characteristic of the culture of most LA countries may offer valuable opportunities and insights for the development of new decolonial approaches to ACP and shared decision making at the end of life. Indeed, the decolonization movement acknowledges that traditional healthcare systems have often been shaped by colonial perspectives, leading to disparities in health outcomes, and seeks to create a more equitable and culturally sensitive healthcare system.[\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOur findings also indicate that, despite the common preference for a relational model of autonomy, as described earlier, the local regulations concerning AD in most countries with normative frameworks tend to adopt a legalistic pattern heavily influenced by the North American model (e.g., requirements for notarization of AD). In addition, the fact that informants from six out of the seven countries that had some form of regulations in that regard reported that, in general, healthcare professionals do not feel safe from a legal/regulatory perspective to perform ACP/AD suggests that regulations by themselves, and particularly so in settings lacking sufficient education of healthcare professionals and the population around palliative care, are often insufficient to support the implementation of those practices.[\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e, \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e, \u003cspan citationid=\"CR92\" class=\"CitationRef\"\u003e92\u003c/span\u003e] Furthermore, our results showed that in countries where healthcare professionals usually establish close and longitudinal relationships with their patients and their families, patient\u0026rsquo;s preferences of care are commonly respected at the end of life even when no regulations around AD are available, as reported for Cuba, Venezuela, and the Dominican Republic. Those results challenge the belief that AD regulations are essential to promote the respect of patients' wishes at the end of their lives[\u003cspan additionalcitationids=\"CR94 CR95 CR96 CR97\" citationid=\"CR93\" class=\"CitationRef\"\u003e93\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e98\u003c/span\u003e]That interpretation expands the understanding derived from previous studies in the US, which argued that AD regulations were often \u0026ldquo;lost in translation\u0026rdquo; and often ended up representing barriers instead of facilitators to that aim.[\u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e91\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe also showed that, despite the existence of similarities between countries, there are also several areas of substantial diversity among them, which highlight the inappropriateness of \u0026lsquo;one-size-fits-all\u0026rsquo; approaches. For example, there was substantial variability concerning informants\u0026rsquo; beliefs about the relevance attributed by their countries\u0026rsquo; populations for exercising control over their healthcare decisions. Other areas of diversity involved, for instance, the extent to which patients\u0026rsquo; values and care preferences are honoured at the end of life, and how the population usually reacts to ACP conversations.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, only four previous studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR100\" citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e] reviewed the state of ACP/AD in LA but these studies focused mostly on the regulatory aspects of AD in the region without addressing the process of ACP in detail as in our study. Notably, the most recent of those studies[\u003cspan citationid=\"CR99\" class=\"CitationRef\"\u003e99\u003c/span\u003e, \u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e100\u003c/span\u003e]shared our interpretation that the existing regulations around AD in LA often are not translated into actual clinical practice. In their review about end-of-life care in LA, Soto-Perez-de-Celis et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] addressed briefly the cultural aspects related to ACP and concurred with our findings of a preference by the population for relational models of ACP, that integrate the patients\u0026rsquo; families into the decision-making processes. Interestingly, another of those studies,[\u003cspan citationid=\"CR101\" class=\"CitationRef\"\u003e101\u003c/span\u003e] when reviewing the literature about AD in LA, argued in favor of a legalist model based on the US framework as the ideal model to be developed in the region without considering the contextual and cultural specificities of these countries and disregarding the preference for relational models of ACP. In marked contrast, the last of those four studies criticized the existing regulations on AD in LA as having an excessive legalist focus and argued in favor of new regulations centered around the process of ACP and including family members in those conversations and decision-making tasks.\u003c/p\u003e \u003cp\u003eOur study has limitations. As previous surveys on PC across countries [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] due to time and resource constraints, we were not able to collect data directly from people living with serious illnesses or their families and caregivers. In addition, we used a single expert informant for each country instead of multiple informants. On the other hand, whilst previous surveys relied on online questionnaires completed by two or more informants, we were able to obtain detailed reports through direct interviews with leading experts in palliative care appointed by national PC associations and to triangulate the information provided by them with legal documents and scientific reports, which enhanced our understanding of the region.\u003c/p\u003e \u003cp\u003eDespite these limitations, our results have relevant implications for policy and research. First, our findings offer a decolonial standpoint that may promote new ways of thinking about ACP/AD, and which invites healthcare professionals and researchers from other regions of the world to rethink ACP/AD in their countries considering their own contexts and cultures. Second, our findings support the development of ACP models in LA that take the religiousness/spirituality of patients and families into account. Third, our results provide evidence that social inequalities may have been shaping who has access to ACP/AD in LA and highlight the crucial role of addressing these inequities to improve end-of-life care in the region.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn summary, our study provides an overview about the state of ACP/AD in 18 out of 20 Latin American countries. Its results encourage rethinking ACP/AD in the region from a decolonial perspective considering regional characteristics such as the common preference for a relational model of autonomy that includes families in the decision-making process, and the importance of taking the religiousness/spirituality of individuals into account during ACP conversations. Furthermore, our findings indicate that honoring patient\u0026rsquo;s preferences of care at the end of life requires more than implementing ACP or legislating about AD. It entails integrating palliative care into health care systems, educating healthcare professionals and the population, and fostering longitudinal trusting relationships between those professionals with patients and their families. Lastly, our study sets the stage for future collaborative investigations among Latin American researchers on a series of relevant topics pertaining to this field, such as cross-cultural studies exploring the views of different populations about ACP, the co-development of interventions and the evaluation of new public policies.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACP - Advance Care Planning\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAD - Advance Directives\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLA \u0026ndash; Latin America\u003c/p\u003e\n\u003cp\u003ePC \u0026ndash; Palliative Care\u003c/p\u003e\n\u003cp\u003eUS \u0026ndash; United States\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study was approved by the Ethics Review Committee of the Botucatu Medical School, São Paulo State University under #57903722.8.0000.5411 on May 5, 2022.\u0026nbsp;\u0026nbsp;All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e All results were presented within the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e NRT was supported by a research scholarship grant by the São Paulo Research Foundation (FAPESP) - grant number 2022/14878-7. The funder did not play any role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e NRT and EIOV designed the study. NRT and LARB performed the interviews. VAT, MGB, DHC, ARN, LRGC, MFS, PB, ATFE, MERAG, TEVC, MOS, NCR, MERR, MEBC, GCP, CFAA, GPA, and IIEG contributed with data and interpretations specific to their countries. NRT and EIOV analyzed the data. \u0026nbsp;NRT, EIOV, FBF, JVDT, LARB, DNF, MICR, RM, ASWP, VAT, MGB, DHC, ARN, LRGC, MFS, PB, ATFE, MERAG, TEVC, MOS, NCR, MERR, MEBC, GCP, CFAA, GPA, and IIEG were involved in the interpretation of findings. NRT and EIOV drafted the first version of the manuscript. FBF, JVDT, LARB, DNF, MICR, RM, ASWP, VAT, MGB, DHC, ARN, LRGC, MFS, PB, ATFE, MERAG, TEVC, MOS, NCR, MERR, MEBC, GCP, CFAA, GPA, and IIEG revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eThe authors wish to express their gratitude to Bianca Sakamoto Ribeiro Paiva, Sabrina Correa da Costa Ribeiro, and Marco Antonio Carvalho Filho for their helpful comments on previous versions of this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSleeman KE, de Brito M, Etkind S, Nkhoma K, Guo P, Higginson IJ, et al. The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. Lancet Glob Health. 2019;7:e883\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, et al. Report of the Lancet Commission on the Value of Death: bringing death back into life. 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Med Int Mex. 2008;24:353\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoreno EG. Decisiones al final de la vida en M\u0026eacute;xico. Entreciencias: Di\u0026aacute;logos en la Sociedad del Conocimiento. 2015;3:267\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuedo P, Sanchez L, Ojeda MP, della Vedova MN, Labra B, Sipitria R et al. Informed consent and living wills: comparative analysis of the legislation in Latin America. Rev Bioet Derecho. 2023;:25\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLatorre EC. Advance care planning: An alternative of regulation in Chile, some aspects from comparative law and the \u0026iacute;nter American convention on protecting the human rights of older persons. Revista de Derecho Privado. 2020;:201\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMonteiro R, da SF. Silva Junior AG da. Diretivas antecipadas de vontade: percurso hist\u0026oacute;rico na Am\u0026eacute;rica Latina. Revista Bio\u0026eacute;tica. 2019;27:86\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Advance Care Planning, Advance Directives, Palliative Care, Aging, Cross-sectional studies, Latin America","lastPublishedDoi":"10.21203/rs.3.rs-4523931/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4523931/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/aims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is unclear whether or how low- and middle-income countries have implemented Advance Care Planning (ACP) and Advance Directives (AD). We aimed to map the current state of ACP/AD in Latin America.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional mixed-methods survey of ACP/AD in LA comprised interviews with 18 key informants from 18 out of 20 countries, most of whom were appointed by national Palliative Care Associations. Interviews occurred online with each informant encompassing various issues ranging from AD regulations to ACP/AD in the context of end-of-life clinical decision making. We performed member checking and data triangulation to confirm our findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnly eight (44%) countries have some form of ACP/AD regulations. Most regulatory frameworks tend to adopt a legalistic pattern heavily influenced by the North American model. Despite that characteristic of AD regulations in LA, the leading strategy used by patients to avoid unwanted treatment at the end of life is through conversations with their families, whereas the least common strategy was consulting with a lawyer. In six (33%) countries, informants believed it was common for patients to grant their families with permission to modify their previous choices regarding future treatments. The religiousness/spirituality of populations plays an important role regarding the implementation of ACP in the region. Additionally, respecting patients’ preferences of care at the end of life appears to be tied more to aspects related to the characteristics of doctor-patient relationship, and the degree of integration of palliative care into the healthcare system than the existence or content of AD regulations. There was consensus that none of the countries provide sufficient education about ACP/AD to healthcare professionals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings encourage rethinking ACP/AD in LA from a decolonial perspective, considering characteristics such as the preference for a relational model of autonomy in several countries and the importance of taking the religiousness/spirituality of individuals into account during ACP conversations. Our data also suggest that honoring patients’ preferences of care at the end of life entails integrating palliative care into health care systems, educating healthcare professionals and the population, and fostering longitudinal trusting relationships between those professionals with patients and their families.\u003c/p\u003e","manuscriptTitle":"Mapping Advance Care Planning and Advance Directives in Latin America","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-31 17:58:22","doi":"10.21203/rs.3.rs-4523931/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-01T04:18:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-28T22:22:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233158033662850128881477388652949459642","date":"2025-03-20T16:58:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5648295597054600219418904978017925613","date":"2025-02-28T07:24:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163008788828655819431053133454790386605","date":"2025-02-25T03:15:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-09T12:56:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"151112728830903537228032315252994585219","date":"2024-10-04T20:26:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66024332695126674914659530057471088633","date":"2024-10-03T08:26:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79525472432107621797330342218991275413","date":"2024-06-28T07:38:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320817262156428074975581637674462011138","date":"2024-06-12T15:55:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-11T21:24:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-11T07:33:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-10T17:18:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-10T17:17:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2024-06-03T20:31:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95159032-2a26-48dd-afcc-aacd7b2b0feb","owner":[],"postedDate":"January 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-12T06:46:08+00:00","versionOfRecord":{"articleIdentity":"rs-4523931","link":"https://doi.org/10.1186/s12904-025-01849-5","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2025-09-06 15:57:04","publishedOnDateReadable":"September 6th, 2025"},"versionCreatedAt":"2025-01-31 17:58:22","video":"","vorDoi":"10.1186/s12904-025-01849-5","vorDoiUrl":"https://doi.org/10.1186/s12904-025-01849-5","workflowStages":[]},"version":"v1","identity":"rs-4523931","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4523931","identity":"rs-4523931","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}