The general public’s perceptions of advance care planning (ACP) in the Asia-Pacific region: a systematic review

The general public’s perceptions of advance care planning (ACP) in the Asia-Pacific region: a systematic review | 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 The general public’s perceptions of advance care planning (ACP) in the Asia-Pacific region: a systematic review Piyawan Pokpalagon, Shirley Chambers, Gursharan K. Singh, Patsy Yates This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5099874/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Apr, 2026 Read the published version in BMC Palliative Care → Version 1 posted 3 You are reading this latest preprint version Abstract Background Populations are rapidly ageing. Advance Care Planning (ACP) is an important activity to help prepare for future healthcare needs. Little is known of the perceptions of the general public of the Asia-Pacific region in relation to these activities. Within the context of the Asia-Pacific region, this review aimed to explore awareness of, attitudes towards, experiences of, and the needs, wishes, and/or expectations related to ACP/Advance Directives (AD) of the general public. Methods The systematic review protocol was registered with PROSPERO (December 17, 2023): CRD42023491109. PubMed, CINAHL, PsycINFO, Embase, and Emcare databases were searched 2013 to 2023 for primary research, of any design, that reported perspectives and experiences of the general adult public of the Asia-Pacific region relating to their awareness, attitudes, experience, and expectations of ACP/AD. Selected studies were quality appraised using the Mixed Methods Appraisal Tool. Findings were synthesised using Cochrane's narrative synthesis approach. Results Out of 3105 records retrieved, 11 studies were included in this review. This review found that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low and it was not uncommon for them to know nothing about substitute decision maker decision makers and other terms related to ACP/AD. While they believe ACP is necessary and important, only a minority have had previous discussions regarding ACP and the reported completion of AD was minimal. Various factors that influence people's willingness to engage in ACP/AD were found, such as wanting legal parameters to protect patient autonomy. Expectations of medical professionals to have good communication skills when discussing ACP were highlighted as well as the need for legal parameters to support ADs. Conclusion This review highlights that awareness of ACP/AD among the general public in the Asia-Pacific region is low. As proven by the small number of papers which informed this review, more robust studies are needed on various aspects of this topic in the context of the Asia-Pacific region. Such studies would inform the best ways to move forward in improving the awareness and knowledge of, and to improve attitudes towards, ACP/AD to ensure people’s treatment decisions are discussed, documented, respected and enacted. Advance Care Planning Advance Directives Awareness Attitude Experience Expectation Public opinion Asia-Pacific Systematic Review Figures Figure 1 BACKGROUND Populations worldwide are aging rapidly with adults aged ≥ 60 years projected to reach 2.1 billion by 2050 [ 1 , 2 ]. This challenge is particularly relevant to the Asia-Pacific region, which encompasses the South-East Asian Region and the Western Pacific Region totalling 48 countries, areas, and territories [ 3 ]. These regions combined have experienced an accelerated pace of population aging, with a higher percentage of populations aged ≥ 60 years compared to other global regions [ 4 ][ 5 ]. As populations age, the prevalence of noncommunicable diseases (NCDs) continues to rise, resulting in individuals living longer with multiple chronic conditions and increasing care complexity [ 4 ]. Despite improvements in detection and therapies, NCDs remain the leading causes of mortality and contribute to substantial health-related suffering due to persistent symptom burden and frequent hospitalisations [ 6 ]. Global projections indicated that health related suffering will continue to increase with the largest rise expected in low-income countries and among adults aged ≥ 70 years [ 7 ]. This increase will be driven by a higher incidence and prevalence of cancers and dementia [ 7 ]; almost 50% of the people with dementia worldwide will reside in the Asia-Pacific region [ 8 ]. The convergence of rapid demographic transition and escalating NCD prevalence highlights the increased and ongoing need to plan end-of-life care (EOLC). One approach to increase EOLC planning is via Advance Care Planning (ACP) which is a process that “enables individuals to identify their values, to reflect upon the meanings and consequences of serious illness scenarios, to define goals and preferences for future medical treatment and care, and to discuss these with family members and healthcare professionals (HCPs)” [ 9 ] (p. e546). Advance care planning has been found to result in many benefits for patients, their family carers, and healthcare systems, such as enabling patients to die in their preferred place [ 10 , 11 ], reduced decision-making burden on family [ 12 ], and reduced lengths of hospital stays which reduces costs to the healthcare system [ 13 ]. Advance care planning may lead to the completion of an Advance Directive (AD), a legal document that provide instructions for medical care on behalf of the patient, in the event the patient is incapable of making their own decisions [ 14 ]. The AD, which is also referred to as a living will by some, may also detail a substitute decision-maker (SDM) [ 15 ]. Despite the well-documented benefits of participating in ACP and completing an AD [ 16 , 17 ], many members of the general public have been found to have negative or unclear perceptions of ACP/AD [ 18 ], which could be mitigated by population-level health behaviour interventions such as public messaging [ 19 ]. This is especially relevant to the Asia-Pacific region, as the implementation of ACP/AD programs for the general public in the community could play an essential role in helping individuals prepare for the EOLC they prefer. Therefore, it is important to understand the level of the public’s awareness of ACP/AD, their perceptions of and perspectives on this topic, and to identify what information and support would be most beneficial in encouraging the general public to consider ACP/AD. However, the majority of reported studies, which explore the perceptions and perspectives towards ACP/AD, are undertaken from the perspective of patients with life-limiting illnesses [ 20 – 23 ], older adults [ 24 – 26 ], their carers [ 22 , 23 , 27 ], and HCPs [ 28 – 32 ]. Recent scoping reviews exploring the general public’s perceptions of ACP from an international perspective demonstrated poor public knowledge of ACP and its purpose and scope, and a general reluctance to name a proxy-decision maker or complete a written AD [ 18 , 33 ]. A systematic review which investigated issues surrounding ACP discussions within an East Asian context found a general lack of understanding and knowledge amongst members of the community as well as a lack of awareness of decision-making rights [ 34 ]. However, the experience of ACP in the Asia-Pacific region may differ due to various cultural values that may affect the general public’s perception, attitudes, experiences and expectations of ACP; this can directly impact engagement with ACP [ 35 ]. The current literature demonstrates that the public’s perception towards ACP/AD in the Asia-Pacific region has not been systematically analysed. To address this gap, this review aimed to identify and explore studies that report the general public’s perceptions of ACP and AD and to provide an evidence base to inform future interventions that aim to increase the general public’s awareness and acceptance of ACP and AD within the Asia-Pacific region. The objectives of this review are, within the context of the Asia-Pacific region, to: explore the general public’s awareness of ACP/AD explore the attitudes of the general public towards ACP/AD explore the general public’s experiences of ACP/AD; and identify and explore the needs, wishes, and/or expectations of the general public related to ACP/AD. METHODS The study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023491109). The review is reported against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 36 ]. Eligibility criteria: The study selection criteria were pre-determined by the Population, Interest, and Context (PICO) framework [ 37 ] for this review. Primary studies of any design reporting awareness, attitudes, experience, and expectations regarding ACP of the general adults (aged ≥ 18) public were included. Only studies with full texts available in English, conducted in the Asia-Pacific region, and published between 2013, the year in which amendments to the Natural Death Act and related policy reforms in several Asian countries [ 38 ] were made, and 2023 were considered. Studies that only report the perspectives of HCPs, a specific age group of individuals, patients with life-limiting illnesses and their caregivers, or fail to separately report findings relating to the adult general public, were excluded. Furthermore, literature reviews, non-published higher degree dissertations and theses, conference abstracts, single case studies, editorials, commentaries, discussion and opinion pieces, guidelines, and other non-research pieces, and non-peer-reviewed articles were excluded. Search strategy: Preliminary searches were conducted in PubMed to identify keywords and terms that align with the review question. The authors then developed a systematic search strategy in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO (EBSCOhost), Embase, and Emcare (via OVID) databases; searches were completed 7 November 2023. Tailored search terms were used for each database, using thesaurus terms (Emtree and MeSH) where applicable (see Additional file 1, Table A1). Study selection: Duplicate records were removed using automated processes in Endnote (Version X9; 2013) [ 39 ] with the help of a university librarian and the web-based application "Rayyan QCRI" (artificial intelligence) [ 40 ], as well as manually. In Rayyan, the title/abstract of the remaining records were screened against the selection criteria for eligibility by two authors independently; one author (PP) reviewed all abstracts and two authors (SC and GS) reviewed an equal portion each. Disagreements on selection were discussed between the two authors; when consensus was not reached, the record was kept for full-text review. The full text of the selected publications was assessed for eligibility independently by two authors using the same division of tasks as per abstract/title screening. Unresolved disagreements were to be discussed with a third independent author (PY), however the need did not arise. Reasons for rejection were recorded. Data extraction and synthesis: A tailored data extraction Excel spreadsheet was developed (see Additional File, Table A2 for details) and pilot tested by two authors (PP and SC). After refinement, data were extracted from each included study by two authors independently, as per the method used for title/abstract screening. Extracted data were compared and discussed and relevant appropriate adjustments made. A meta-analysis of findings was not possible due to the heterogeneity of outcome measures and most surveys used were not validated. Hence, a narrative synthesis approach, which has been found to be well-suited to synthesising evidence [ 41 ], was used to collate and group data. This synthesis was underpinned by Cochrane methods [ 42 ]. Categorisation of the included studies’ findings was undertaken upon consensus amongst the review authors. Quality Appraisal and Risk of Bias: The Mixed Methods Appraisal Tool (MMAT, Version 2018) [ 43 ] was used to appraise the overall methodological quality of included studies as no study design, other than single case studies, was excluded from this review. This tool [ 43 ] assesses five methodological criteria as relevant for different types of study designs. Each included study (publication) was independently appraised for methodological quality by two authors using the same method of distribution as per title/abstract screening. Studies were not excluded due to low methodological quality, rather the overall quality of the studies was of interest. No score of quality was calculated as this is discouraged by the MMAT developers [ 43 ]. However, to gain a sense of quality across studies, they were classified based on the number of criteria met (as agreed upon by two authors) with studies meeting four (80%) or five (100%) criteria considered high quality, those meeting two (40%) or three (60%) criteria considered medium quality, and those meeting only one (20%) or none (0%) considered low quality. Risk of bias was further addressed through transparent and rigorous review procedures. The search strategy was developed with input from a world-class expert in the field (PY) and a university health librarian, and a variety of reputable academic databases were searched. These processes ensured a broad range of studies would be included. Furthermore, the review protocol was prospectively registered with PROSPERO and reference lists of included studies were examined for additional eligible studies. RESULTS Study selection Literature searches yielded 3105 records. After duplicates were removed, the screening of 2325 abstracts resulted in 95 records retained for full text review. From these, 84 articles were excluded with most due to not focusing on the general public (see Fig. 1 for details). Ultimately, 11 studies met the inclusion criteria and were included in the final review. The study characteristics of the included studies are detailed in Table 1 . Table 1 Summary Table: Main characteristics and limitations of included studies Author/Year/ Country Aim/s Study design Methods Participants Questionnaire Limitations MMAT 1 (%) Chan et al., 2019 Hong Kong SAR (China) To examine prevalence, perception, and predictors of AD completion in the Hong Kong general population with a diverse culture Quantitative: Population-based cross-sectional Random sampling; Phone survey n = 2002 Hong Kong general population aged ≥ 18 who communicate in Chinese (response rate: 42.8%; cooperation rate: 43.7%) Age : ≥45 years 58.6% Gender : Female 55.8% Religious : None 78.9% Education : Senior secondary or higher 70.2% - Developed by research team, Five-part questionnaire includes: 1) socio-demographic characteristics, 7 items; 2) self-perception and health status, 6 items; 3) the prevalence of AD, 2 items; 4) perceptions related to AD, 8 items; 5) making AD in various scenarios, 7 items. Reliability : Cronbach's alpha 0.81 Validity : Not reported - Study's cross-sectional nature hampers identifying causal relationships between predictors and AD completion. - Use of phone interviews may have excluded eligible participants without a phone – sampling bias. - Low response rate may have introduced bias. 80 Chung et al., 2017 Hong Kong SAR (China) To describe knowledge, attitudes, and preferences of the general Hong Kong adult population across different age groups regarding EOLC decisions, place of care and death, as well as AD Quantitative: Population-based cross-sectional Random sampling; Phone survey n = 1067 Hong Kong Chinese residents aged ≥ 30 years who spoke Cantonese Age : ≥ 40 years 88.5% Gender : Female 62.7% Religious : None 69.6% Education : Secondary or higher 68.7% Formulated by research team to obtain information regarding knowledge, attitudes, and/or preferences toward advance decisions and EOLC - Reliability : Not reported - Validity : Not reported - Caution needed when inferring causal relationships between predictors and outcomes due to study design. - Those without a phone may differ from the general public – sampling bias. - Phone interviews were time-constrained, thus can potentially affect accuracy of responses. 60 Groenewoud et al., 2020 Japan & Netherlands To compare Dutch and Japanese general public’s attitudes and preferences toward EOLC, and EOL decisions - Quantitative: Cross-sectional Quota sampling strategy by age, gender, and living areas - random sampling strategy – sent emails; Online survey n = 1038 Japanese general public aged ≥ 20 years n = 1040 Dutch general public aged ≥ 20 years ( Note : only findings of the Japanese general public used in this review) Age : ≥40 years 80% Gender : Female 50% Religious : N/A Education : Moderate to High academic 80.1% - No details of the questionnaire used in this study were provided in this paper - Small sample size did not allow for sub-analyses on regional variation. - Using quota sampling method did not result in a representative sample for age, urbanisation, education, and income. - Using a panel, rather than recruiting respondents from the public by hand, may have biased the results. - Multiple comparisons were not adjusted for due to the exploratory nature of the study. 60 Keam et al., 2013 Korea - To investigate Korean attitudes toward AD among cancer patients, family caregivers, oncologists, and the general public. - To identify factors associated with a favourable perception toward AD Quantitative: Multicentre - Phone interview survey with structured questionnaire for general public, conducted by professional interviewer - In-person survey for patients, family caregivers, and oncologists n = 1006 Korean general public aged 20–70 years n = 1242 cancer patients n = 1289 family caregivers n = 303 oncologists ( Note : only general public findings used in this review) Age : ≥40 years 52% Gender : Male 50.4% Religious : No religion 37.4% Education : College or higher 49.2% - Structured questionnaire developed by researchers, which includes: 1) Demographic details 2) Necessity of AD 3) Optimal timing of AD 4) Necessary items for AD form 5) Disclosure of terminal status, HPC, withdrawal of futile life-sustaining treatment, & euthanasia. - Reliability : Not reported - Validity : Not reported - The survey was conducted by phone with the general public, which differs from the data collection method used with other participants. 80 Leong et al., 2021 Macao To explore Macao Chinese residents’ willingness to make ADs, and to identify predictors of their willingness to make ADs Quantitative: Cross-sectional Non-probability quota sampling by age; Online survey and face-to-face interviews n = 724 Macao residents aged ≥ 18 years (completion rate 72.3%) 86.2% were self-administered online 13.8% were completed face-to-face by interviewers Age : ≥40 years 57.9% Gender : Female 64.9% Religious : No religion 57.7% Education : College or higher 57.2% Structured questionnaire, written in Chinese by research team: 4 sections: 1) Sociodemographic profile; 2) Self-rated health; 3) Preferences of EOL treatment and attitudes towards EOLC; 4) Willingness to make AD. Reliability : Not reported Validity : Not reported The Hospice Care Attitude Scale assessed participants’ attitudes towards EOLC. Reliability : Cronbach’s coefficient 0.79; test-retest reliability 0.94. Validity : Item–Content Validity Index = 1.00; good level of Construct Validity - Limited representativeness - non-probabilistic quota sampling to match age distribution of participants with Macao population - Self-selection bias – those who consented may reflect positive attitudes towards EOLC issues. - Potential bias due to using both online and face-to-face interviews; primarily collecting data from online surveys. - Potential bias due to the higher education and professional occupations of participants. 80 Lim et al., 2022 Malaysia To assess knowledge, attitudes and practice (KAP) among community-dwelling adults in Malaysia regarding ACP, and its associated factors Quantitative: Cross-sectional- Face-to-face interviews undertaken by trained researcher n = 385 community-dwelling adults (response rate 98%). Age : Median 61 years Gender : Female 55.8% Religious : Islam 38.4% Education : Secondary or higher 85.5% - English or Malay ACPQ, 4 domains: 1) Demographics 2) Knowledge 3) Attitude 4) Practice of ACP. Reliability : Cronbach’s alpha values for items in each domain range:0.637–0.915. In test-retest, kappa values range: 0.738–0.947 [ 64 ]. Validity : Factor analysis of 22 items revealed 4 domains and found to be valid instrument - Recruitment of community-dwelling adults from a single site - may have affected the generalisability of this study. - Acquiescence bias as a result of interviewer-assisted questionnaires is possible. - Testing knowledge was not possible because of the limited awareness. 60 Ng et al., 2017 Singapore - To investigate awareness of local Singapore community towards ACP - To ascertain their willingness to engage in ACP discussions - To identify factors that affect an individual’s willingness to participate in ACP Quantitative: Cross-sectional Two-stage stratified random sampling; face-to-face interviewer-lead survey by trained fourth-year medical students n = 406 community dwellers of Housing and Development Board flats (completion rate 23.37%) Age : Mean 46.8 Gender : Female 53.1% Religious : Buddhism 23.4%, No religion 22.7% Education : Secondary or higher 84.8% - Researchers developed 23 close-ended questions that evaluated respondents’ awareness and knowledge of ACP, willingness to engage in ACP, and factors influencing willingness to undergo an ACP discussion. - Questionnaire was developed in English and translated to Chinese. - Questionnaire was pilot tested with n = 40 randomly selected community-dwelling individuals and refined Reliability : Not reported Validity : Not reported - Participation bias – residents who were non-English or non-Mandarin speaking or living in private estates were excluded. - Poor response rate - Self-selection bias: survey participates may be more receptive to talking about EOL issues than those who declined. - Social desirability may have influenced respondents’ willingness to engage in an ACP discussion after education. 60 Ni et al., 2021 China Among Chinese adults: - To describe knowledge and attitudes of AD and EOLC preferences - To explore factors related to preferences for AD Quantitative: Cross-sectional Online survey through a link in a short phone text message n = 1114 Chinese residents aged ≥ 18 years living in Wuhan Age : Mean 48.03 Gender : Female 65.3% Religious : No religious 90.3% Education : Associate degree or higher 68.2% Knowledge and preferences for AD and EOL care assessed using a tool designed for older Chinese adults which has been used with nursing home residents in Hong Kong and Wuhan Reliability : Not reported Validity : Not reported - Sampling bias due to individuals being registered in 8 household management centres in Wuhan and due to self-selection bias. - Generalisation of findings to China’s population is not guaranteed. - Only residents with smartphones could access survey, excluding opinions of those without a smartphone. 40 Park et al., 2019 South Korea To investigate awareness and attitudes towards ACP in South Korea Quantitative: Multicentre (nationwide) cross-sectional - Phone survey of general public - Face-to-face survey for cancer patients and family caregivers - Online survey for physicians n = 1005 general public aged 20–70 years n = 1001 cancer patients n = 1006 Family caregivers n = 928 Physicians (Note : only general public findings used in this review) Age : >50 years 42.8% Gender : Female 50.8% Religious : No Religious 58.2% Education : High school or higher 63.8% - Structured questionnaire developed by researchers, which includes: 1) Awareness of ACP 2) Willingness to conduct ACP 3) Suitable timing to write an AD 4) Strategies to facilitate ACP 5)Sociodemographic details Reliability : Not reported Validity : Not reported - The questionnaire focused on hypothetical scenarios, therefore attitudes and behaviours when faced with a real situation could be different. - The Korean healthcare system and policy regarding ACP could influence results. 60 Sellars et al., 2021 Australia To describe the Australian adult public’s knowledge and experiences regarding SDM for medical decisions and their preferences for obtaining information about the SDM role Quantitative: National cross-sectional Adults who voluntarily signed up to a recruitment agency register (Dynata) were invited to complete survey; Online survey via the company’s website n = 1120 Australian adults aged ≥ 18 years residing in Australia at the time of the study (completion rate 70.6%) Age : ≥40 years 64.3% Gender : Female 55.3% Religious : No religion 37.5% Education: Senior secondary or higher 89.1% The survey was developed by a research team and refined after a pilot with 14 adult Australians to assess question comprehension The survey comprised: 1) Demographic information 2) Knowledge: ACP and SDM 3) Attitudes: SDM 4) Needs, concerns, and intentions: SDM 5) Resource development Reliability : Not reported Validity : Not reported - More women than men responded to survey. - Participants were not totally representative as they were older than the available estimates for the Australian public overall. - Due to the opt-in sampling methodology, the generalisability of findings may be limited. 80 Whyte et al., 2022 Australia To explore cognitive and behavioural biases that influence individual’s willingness to engage ACP Quantitative: Cross-sectional - General public recruited via a commercial research company - Online survey - In person survey for healthcare professional n = 1248 Australian adults aged 18–80 years n = 117 HCPs recruited from conference attendees of the General Practice Conference and Exhibition Age : Mean 41.3 years Gender : Male 45.5% Religious : N/A Education : N/A - Topic covered: 1) Demographics 2) Preference for ACP decision-making 3) Cognitive bias tests (6 items) 4) Personal experience with ACP (3 items) Reliability : Not reported Validity : Not reported - Generalisability may be impacted by convenience sampling method. - Study does not account for potential patient cognitive impairment, which is often the catalyst for initiating ACP discussions and processes. 80 ACP - Advance Care Planning, ACPQ - ACP Questionnaire, AD - Advance Directive, DNACPR - Do Not Attempt Cardiopulmonary Resuscitation, EOL – End-of-Life, EOLC – End-of-life Care, EPA - Enduring Power of Attorney, HCPs – Healthcare Professionals, HPC - Hospice–Palliative Care, KAP - Knowledge, Attitude and Practice, SDM - Substitute Decision Making Place Fig. 1. here Figure 1. The PRISMA flow diagram Place Table 1 here Quality appraisal All included studies were of a quantitative descriptive design therefore were appraised as per the criteria set out in the MMAT for this study design type, which includes: (1) relevance of the sampling strategy, (2) representativeness of the sample, (3) appropriateness of measurements, (4) risk of nonresponse bias, and (5) appropriateness of statistical analyses. Two authors agreed all but one study met four (n = 5 studies) or three (n = 5 studies) of the five appraisal criteria, hence 91% of included studies (n = 10) were considered to be of medium to high quality. Only one study was considered to be of low quality. The ‘risk of nonresponse bias’ was the most common criterion that was appraised as either not able to be determined (n = 6 studies) or not being met (n = 1 study). Appropriateness of statistical analysis’ methods was agreed on by both authors across all included studies (See Additional file 1, Table A3 for full details). Characteristics of included studies: Country and date Six countries in the Asia-Pacific region are represented in this review. Four of the included studies were conducted in China or from Special Administrative Regions (SAR) of China, which includes one from China [ 44 ], two from the Hong Kong SAR [ 45 , 46 ], and one from Macao SAR [ 47 ]. Two studies were conducted in Australia [ 48 , 49 ], two in the Republic of Korea [ 50 , 51 ] and one study also originated from Japan [ 52 ], Malaysia [ 53 ], and Singapore [ 54 ]. Although searches were conducted from 2013, most of the included studies (n = 10) were conducted between 2017 and 2022 [ 44 – 49 , 51 – 54 ]. Sample characteristics All participates in the included studies were considered to be adults (aged ≥ 18 years) however the inclusion criterion for minimum age of studies varied with the age of some samples starting at 20 years [ 50 – 52 ], 21 years [ 53 , 54 ], and from 30 years of age [ 46 ]. We are unable to report a collective mean age of participants across studies as some only reported against age groupings, e.g., 45–65 years. Most studies had similar ratios of male and female participants (female 50–65%). Study participants had, primarily, moderate to high levels of education (secondary school, college, and higher), and most reported having no religious beliefs. Sample sizes of the included studies ranged from 385 to 2002 with most studies (n = 8) having samples of over 1000 participants [ 44 – 46 , 48 – 52 ]. See Table 1 for all study characteristics. Studies’ design and data collection methods All included studies were of a quantitative, cross-sectional design. All but one of the included studies investigated ACP as part of broader structured questionnaires that also sought data on awareness and attitudes towards, experiences with, and preference for ACP/AD; one study did not mention the questionnaire used in the study [ 52 ]. Surveys were completed by telephone [ 45 , 46 , 50 , 51 ], online [ 44 , 48 , 49 , 52 ], face-to-face [ 53 , 54 ], and both online and face-to-face [ 47 ]. Not all surveys used across the studies were validated. See Table 1 for validation details. Overview of main findings: Findings were broadly categorised into four main groupings that align with the review’s objectives, the general public’s: awareness of; attitudes towards; experiences with; and needs, wishes, and/or expectations of ACP/AD. (see Table 2 for brief overview, Table 3 for details of findings, and Table 4 for themes and sub-themes of findings). Table 2 Included papers reporting on the outcomes of interest Author/Year/Country Awareness Attitudes Experience Expectations /Preferences Chan et al, 2019; Hong Kong SAR (China) √ √ √ √ Chung et al, 2017; Hong Kong SAR (China) √ √ √ Groenewoud et al, 2020; Japan & Netherlands √ Keam et al, 2013; Korea √ √ Leong et al, 2021; Macao (China) √ √ Lim et al, 2022; Malaysia √ √ √ √ Ng et al, 2017; Singapore √ √ √ √ Ni et al, 2021; China √ √ Park et al, 2019; South Korea √ √ √ Sellars et al, 2021; Australia √ √ √ Whyte et al, 2022; Australia √ √ √ √ Total Studies Reporting Outcomes of Interest 8 9 5 10 Table 3 Summary table: Awareness, attitudes, experiences, and expectations of ACP/AD in Asia-Pacific region Author/Year/ Country Results Awareness Attitudes Experience Expectations/ Preferences Chan et al., 2019 Hong Kong SAR (China) - n = 368 (18.4%) had heard about AD - n = 1629 (81.4%) had not heard of an AD - n = 5 (0.2%) cannot remember if head about AD - 82.1% AD is a basic human right. - 72.7% promotion on AD in community adequate. - 77.8% patients should have a clear mind and be mentally prepared when considering making AD. - 77.5% HCPs should have good communication skills when discussing making AD with patients. - 71.8% family members of patient should engage in discussing making AD. - ‘Variables: Employment status’, ‘religion’, ‘self-perceived level of optimism’, and ‘level of agreement that patients’ will and decisions’ should be respected were significantly and independently associated with the level of acceptance on AD completion. - Compared with the employed, students were significantly associated with a lower level of acceptance (B: -5.89, SE: 1.41, p < 0.001). - With reference to those without any religion, a higher degree of AD acceptance was significantly associated with Christianity (B: 5.12, SE: 1.32, p < 0.001), Catholicism (B: 4.78, SE: 2.37, p = 0.044), and Buddhism (B: 8.19, SE: 1.85, p < 0.001). - Compared with participants perceiving themselves as pessimistic, increasing levels of acceptance on AD completion were found among those who were becoming more optimistic (B ranged from 4.32 to 9.49, all p < 0.001). - A higher level of agreement by participants on the statement that patients’ wishes and decisions should be respected was found to be associated with a higher the level of acceptance on AD completion, when compared with those that disagreed with the statement (B ranging from 6.22 to 20.11, all p < 0.05). - n = 11 (0.5%) Had an AD - n = 357 (17.8%) Did not have an AD - n = 295 (14.7%) Had made AD or intend to make AD For the discussion of AD: - n = 1,558 (77.8%) Patients should have a clear mind and be mentally prepared when considering making an AD. - n = 1,515 (75.7%) HCPs should possess good communication skills when discussing making an AD with patients. - n = 1,439 (71.8%) Family members of the patient should be engaged in discussions for making an AD. Chung et al., 2017 Hong Kong SAR (China) - n = 153 (14.3%) had heard of AD - n = 333 (31.2%) had heard of DNACPR - n = 103, (9.7%) had heard of EPA - n = 215 (64.60%) knew what DNACP and n = 52 (50.5%) knew what EPA were (among those who had heard of types of advance decisions) - n = 788 (73.9%) agreed it was a good approach to make an AD before they became mentally incompetent (after explaining about AD). - n = 650 (60.9%) would make an AD if AD were legislated - Would not make an AD due to: • n = 127 (52.7%) possibility of changing their mind • n = 33 (13.7%) being inconvenient/troublesome to do so • n = 28 (11.6%) being afraid of being deprived of desired/needed care • n = 62(25.7%) other reasons - Being a female participant significantly reduced the chance of making an AD by 1.30 times. - Having prior knowledge of DNACPR significantly increased the chance of making an AD by 1.87 times. - n = 920 (86.2%) agreed that patients’ own wishes should determine what treatment they should receive. - n = 984 (92.2%) believed that it is a good practice for medical staff to talk to patients directly about their situation and EOL care. - n = 931 (87.6%) indicated that they would prefer to receive appropriate palliative care that gives comfort even though it may not prolong life. - n = 132 (12.4%) chose to prolong their lives with medical interventions for as long as possible. Groenewoud et al., 2020 Japan (& The Netherlands – note only results from Japanese reported here) - n = 676 (65.1% of Japanese cohort) reported that they would be happy for doctors to pro-activity confront them with their future death, and talk with them about goals in life done in ACP - n = 191 (18.4% of Japanese cohort) reported that ACP is too confronting and that they would expect a doctor to give them hope Keam et al., 2013 Korea - n = 934 (94.9%) of general public agreed with the necessity of AD - Optimal timing for completing AD: • n = 335 (33.9%) When cancer diagnosed • n = 313 (31.7%) When in terminal status • n = 26 (27%) When Healthy • n = 73 (7.4%) When death is Impeding - Age, education, attitude toward terminal illness, and attitudes toward hospice-pall care found to be significantly associated with attitudes to AD (P < 0.001). - Younger age (p = 0.006), higher education (p = 0.002), agreement with the disclosure of terminal illness (p = 0.001), a positive attitude toward the withdrawal of futile life-sustaining treatment (p = 0.003), a positive attitude toward active pain control in terminal cancer patients (p < 0.001), and a positive attitude towards hospice and palliative care (p < 0.05) were found to be independently associated with the necessity of AD. General public’s preferences of necessary items in AD form: - n = 880 (90.8%) Explanation for Hospice and Palliative Care - n = 786 (81.5%) CPR - n = 793 (81.7%) Artificial Nutrition and Hydration - n = 776 (80.7%) Antibiotics use - n = 742 (77.8%) Haemodialysis - n = 758 (77.2%) Mechanical ventilator: # Chi-square P < 0.001 Leong et al., 2021 Macao (China) - n = 533 (73.6%) would complete an AD if document was recognised legally. - n = 50 (6.9%) would not complete an AD. - n = 141 (19.5%) did not know or were undecided about completing an AD. - Top three reasons of those unwilling to set up AD : • n = 104 (54.5%) did not know the specific content of AD • n = 81 (42.4%) did not know the procedures of setting up AD • n = 79 (41.4%) afraid that they might change their mind after setting up AD - Predictors of willingness to make AD : • Age, educational level, marital status, average monthly income in the past year, caring experiences, EOL treatment option, and the score of the Hospice Care Attitude Scale were found to be significantly correlated with willingness to make AD. • Caring experiences, EOL treatment options, and the score of the Hospice Care Attitude Scale • Respondents who had cared for relatives or friends with terminal illnesses were more willing to make AD than those who had not (OR = 1.68, 95% CI [1.14, 2.49]). • Respondents who chose suffering-alleviating treatments, despite knowing that their limited lives might not be extended, were more likely to set up AD than those who chose life-prolonging treatments (OR = 2.20, 95% CI [1.53, 3.17]). • Those who scored higher in the Hospice Care Attitude Scale were more willing to make AD (OR = 1.06, 95% CI [1.02, 1.10]). n = 619 (85,5%) expressed that it was necessary to discuss the treatment and care at the end of their lives with HCPs Lim et al., 2022 Malaysia - n = 12 (3.1%) had heard of ACP - n = 20 (5.2%) were familiar with ACP concepts Had not heard of : - n = 361 (93.8%) SDM - n = 346 (89.9%) EOL decision making - n-220 (57,1%) living will - n = 290 (75.3%) durable power of attorney The most common sources of information for those familiar with ACP were - n = 62 (161%) mass media - n = 39 (10.2%) friends - n = 32 (8.3%) reading materials - n = 26 (6.8%) relatives - n = 12 (3.1%) family doctors After the term ACP was explained - n = 331 (86%) ACP services should be provided in primary care clinics - n = 330 (85.7%) felt that discussion on ACP was necessary - n = 325 (84.4%) were willing to discuss ACP in the future - n = 311 (80.8%) were in favour of ACP. - n = 75 (19.5%) had thought of writing a living will n = 23 (6%) had written a living will. Choice of SDM were : - n = 124 (38.2%) spouse - n = 122 (37.5%) family members - n = 77 (23.7%) preferred HCPs - n = 2 (0.6%) close friends Preferences for AD : - n = 277 (84.2%) verbal directive to a family member or acquaintance - n = 221 (67.2%) written documentation and to give a copy to their healthcare provider and family - n = 74 (22.4%) audio or video tape recording of wishes When is right time to complete AD : - n = 278 (72.2%) if had dementia (n = 308; 80.0%), cancer (n = 305; 79.2%), heart attack and on a breathing machine (n = 283; 73.5%), or in a coma (n = 267; 69.4%) - More than 80% agreed ACP topics should include CPR, use of artificial breathing machine, tube feeding, place of death, haemodialysis, place of care, and chemotherapy Ng et al., 2017 Singapore - n = 58 (14.4%) had heard of ACP, mostly through the media (67.9%), from family and friends (21.4%) and healthcare providers (21.4%) - Respondents who were previously aware of ACP were more likely to be older, Singaporean, and tended to make important personal decisions on their own as compared to those who have not heard about ACP - There was no association between the respondents’ knowledge scores and the channels through which they had learned about ACP Top 3 reasons for being unwilling to begin an ACP discussion after learning more about ACP were : - n = 55 (35%) still healthy - n = 22 (14%) thinks ACP is unnecessary - n = 14 (8.9%) would like family to make that decision Common reasons to discuss ACP were : - n = 340 (83.7%) having a serious life-threatening illness - n = 312 (76.8%) if the respondent knew more about ACP (76.8%) - n = 303 (74.6%) if the respondent was an older age - n = 236 (60.1%) were willing to begin an ACP discussion after being education about ACP - Those who were willing to begin an ACP discussion were more likely to be receiving financial support from their family (40.7% vs 30.6%, P = 0.042, χ² = 4.1, df = 1). - There was also a trend towards those who tend to make important personal decisions together with their family (60.4% vs 48.4%, P = 0.051, χ² = 6.0, df = 2) and those with university or higher education qualification (31.8% vs 21.0%, P = 0.051, χ² = 9.4, df = 4) were also more likely to have greater willingness to begin an ACP discussion. - 26.8% of those who had previously heard of ACP knew how to begin an ACP discussion, 12.5% of them had a prior ACP discussion. - There were 7 (12.5%) of the 56 respondents who had a previous discussion regarding ACP. - Respondents who were more likely to have had a previous ACP discussion were those who had answered ""yes"" to knowing how to begin an ACP discussion (71.4% vs 20.4%, P = 0.012) - The top 3 methods which respondents perceived as good methods for learning more about ACP were advertisements in the media (86.9%), general practitioners or other healthcare providers advocating ACP (70.4%) and brochures given out by the government (62.6%). Ni et al., 2021 China - n = 700 (62.8%) had heard of life-sustaining treatments - n = 203 (18.2%) had heard of AD n = 203 - n = 691 (62.0%) The main reason given to complete an AD was to ease burden on their families and to make decisions for themselves. - n = 965 (86.6%) were willing/fairly willing, after learning about AD, to make their EOL treatment decision s(AD) if it was legal. The main reasons for reluctant to make an AD were : - n = 528 (47.4%) It is too early to make one - n = 371 (33.3%) The law is not perfect - n = 371 (33.3%) It is no use to make one - n = 330 (29.6%) Not familiar with it Park et al., 2019 South Korea Of the n = 1005 individuals: - n = 162 (16.1) knew about AD - n = 102 (10.2%) were aware of physician orders for life-sustaining treatments Willingness to conduct ACP when : - n = x (46.5%) healthy - n = x (56.5%) diagnosed with serious disease - n = x (63.6%) the disease state was aggravated - n = x (68.3%) the status was terminal Reasons for lacking the intention to prepare an AD : - n = 216 (30.5%) feel psychologically anxious or uncomfortable preparing for worsening health problems - n = 147 (20.8%) would change their mind when faced with the situation in the future even if they make the decision now - n = 96 (13.6%) not sure if things will be handled as per their wishes and reflected in AD - n = 85 (12%) their family will make a wise decision when they are unable to do so - n = 78 (11%) do not know much about AD Suitable times for writing an AD were : - n = 542 (32.6%) before all procedures or interventions with a high mortality risk - n = 430 (25.9%) when visiting wards and emergency rooms of patients with specific severe diseases - n = 342 (20.6%) when the patient was aged > 65–70 years when recently admitted to the hospital Strategies for Facilitating ACP : - n = 359 (35.7%) public promotion efforts and education regarding ACP - n = 191 (19%) online programs and n = 191 (19%) setting up offices where an AD could be registered - n = 142 (14.1%) Providing payment for ACP through national medical insurance Sellars et al., 2021 Australia - n = 431 (38.5%) had heard of ACP - 58% reporting they did not know if there were laws regarding SDM. - 33% reporting awareness of SDM laws existing in Australia. - The median knowledge scores for people who had ever discussed ACP (3.0 vs 2.0, U = 1 45 222, z = 6.910, p < 0.001), documented their ACP preferences (3.0 vs 2.0, U = 71 984, z = 4.087, p < 0.001), or acted in the SDM role (3.0 vs 2.0, U = 56 353, z = − 3.694, p < 0.001), were significantly higher compared with those who had not. - Source of learning or hearing about ACP (n = 431) n = 262 (60.8%) family and friends n = 202 (46.9%) media n = 173 (40.1%) HCP - n = 117(10%) had completed ACP documentation. - Of those who had been involved in an ACP discussion with other people (n = 267) • n = 163 (61%) had told someone about their future treatment preferences. • n = 50 (30%) had documented ACP preferences. • n = 230 (86%) had discussed the ACP preferences of someone. • n = 142 (13%) had acted as an SDM. - Preferred source(s) of obtaining more information to support SDMs to make their decisions were (n = 1049) • HCPs (59%, n = 621), • discussion with a family member or friend (23%, n = 236), • traditional media (7%, n = 69), • new media (6%, n = 61), • an ‘other source’ (3%, n = 35) • an event (3%, n = 27) Whyte et al., 2022 Australia - 33.3% knew about ACP - There is a positive correlation between the age of the general public and the preferred age for the initial ACP discussion (. = 0.368, p < 0.001). - Australian males seem to prefer a slightly later initial ACP discussion in life (M = 59.4 years, SD = 14.8) compared to Australian females (M = 57.1 years, SD = 14.3; p = 0.0047) - 14.1% have participated in ACP - 21.1% have been involved with ACP of their friends or relatives - The ideal age of initial ACP discussion is 58.1 years (SD = 14.56) - The mean share of doctor's ACP input is 39 (SD = 31.3). ACP - Advance Care Planning, AD - Advance Directive, DNACPR - Do Not Attempt Cardiopulmonary Resuscitation, EPA - Enduring Power of Attorney, HCPs – Healthcare Professionals, SDM - Substitute Decision Making, EOL – End-of-life. Statistical notes : B - Regression coefficient, M – Mean, OR - Odds Ratio, SD - Standard Deviation, SE - Standard Error Place Table 3 here Table 4 Summary of outcome categories (themes), and sub-themes from included studies Outcome category (theme) Sub-theme Awareness of ACP/AD Type of awareness assessed Awareness and knowledge of ACP/AD Factors influencing awareness of ACP Attitudes towards engaging with ACP/AD Factors influencing attitudes towards engaging with ACP/AD - Legal issues - Age - Health status - Knowledge and education - Timing - Family matters - Additional factors Experiences of ACP/AD Experiences of ACP Experiences of AD Preferences and expectations of ACP/AD Preferences of ACP/AD - Promotion of ACP - AD documentation - Timing to engage in ACP/AD Expectations of ACP/AD - Items on AD forms - Healthcare Professionals ACP: Advance Care Planning; AD: Advance Directive Awareness of Advance Care Planning/Advance Directive Eight of the 11 studies assessed the general public’s awareness of ACP/AD. The terms used in these studies were interchangeable, referring to awareness and knowledge to evaluate the same phenomenon. Type of awareness assessed Participants were asked subjective questions of awareness/knowledge of ACP/AD in eight studies [ 30 , 44 , 45 , 48 , 49 , 51 , 53 , 54 ] and two studies [ 48 , 54 ] assessed awareness/knowledge of ACP including knowledge of SDM both subjectively and objectively using true-false statements. Awareness and knowledge of Advance Care Planning/Advance Directive The general public’s awareness of ACP in the Asia-Pacific region was found across three studies, ranging from around 3% [ 53 ] to 39% [ 48 ] of study participants. The findings demonstrate that around one in three people knew about ACP [ 49 ] and that it was common for participants to not know about other aspects of ACP such as the role of the SDM [ 48 , 53 ] and were not aware of the terms ‘EOL decision making,’ ‘living will’ or ‘durable [sic] power of attorney’ [ 53 ]. However, more than half (55%) of the participants in the Sellars et al. [ 48 ] study knew about ways to plan for future medical care when they could not make decisions for themselves. Similarly, awareness of AD was low across participants ranging from 14% [ 46 ] to 43% [ 53 ] across studies. Terminologies related to AD were also reported by few, for example, less than 10% of participants in Hong Kong had heard of ‘enduring power of attorney’ (EPA) [ 46 ], and less than half (n = 165, 43%) of community-dwelling adults in Malaysia had heard of a ‘living will’ [ 53 ]. The most common sources of ACP/AD information reported were the media, family and friends, HCPs, as well as other sources including legal practitioners and financial planners [ 48 , 53 , 54 ]. Factors influencing awareness of Advance Care Planning Only two studies reported on factors that influence awareness of ACP. The primary factors reported were being of an older age and making important personal decisions autonomously when compared to those who had not heard about ACP [ 54 ]. One of the Australian studies [ 48 ] found that the median knowledge scores for people who had ever discussed ACP (3.0 vs 2.0, p < 0.001), documented their ACP preferences (3.0 vs 2.0, p < 0.001), or acted in the SDM role (3.0 vs 2.0, p < 0.001), were significantly higher compared with those who had not. Attitudes towards engaging with Advance Care Planning/Advance Directive Nine of the 11 included studies assessed the general public’s attitudes toward ACP/AD. Findings include being supportive of ACP, though few (20%) had thought of writing a living will [ 53 ], that the ACP/AD is useful and necessary [ 47 , 50 , 53 ], and that having an AD was viewed as a basic human right [ 45 ] with many being happy to discuss ACP in the future [ 53 ]. Many agreed that an AD was a good approach to determine health care decisions prior to becoming mentally incompetent [ 45 , 46 ]. Furthermore, good communication skills and practices of clinicians when talking to patients and their families directly about ACP/AD, was considered favourable [ 45 , 46 ]. Factors influencing attitudes towards engaging with Advance Care Planning/Advance Directive In the context of the Asia-Pacific region, factors that influence the general public’s attitudes toward ACP/AD and engaging in relevant discussions and processes were found to be across legal issues, age, health status, knowledge and education, timing of such discussions, family matters, and more. Legal issues The legal status of ADs was found to impact participants’ attitudes toward completing an AD [ 44 , 46 , 47 ] with participants noting that they would complete an AD if it was legislated [ 46 ]. Non-specific problems with the law were also noted as deterrents to completing an AD [ 44 ]. Age Age was found to be associated with willingness to engage in ACP/AD. Participants’ age and their preferred age to initiate ACP discussions were positively correlated (ρ = 0.368, p < 0.001 respectively) [ 49 ]. Feeling too young to complete an AD was reported across studies [ 47 , 54 ]. In contrast, the Keam et al. [ 50 ] study found that younger age (20–49) was associated with a sense of necessity for an AD compared with those aged ≥ 50 years (p = 0.006). This may be due to older participants being potentially closer to the end of their lives than those younger, and hence do not wish to be reminded of their mortality. Health status Poor health status, or having a serious life-threatening illness, was a factor associated with the willingness to engage in ACP/AD. This included the possibility of having a life-limiting illness, such as cancer or dementia, undergoing a life-sustaining treatment [ 53 , 54 ] or poor self-ratings of health [ 44 ]. Congruent to this, feeling healthy was the most common reason given by those unwilling to begin an ACP discussion [ 54 ]. Knowledge and education Prior awareness or knowledge of ACP/AD was found to be associated with engagement, consequently, lack of such knowledge appeared to hinder engagement. Two studies found that education of ACP/AD, and having a higher education, was related to willingness to complete an AD [ 44 , 54 ]. Furthermore, prior knowledge of life-sustaining treatments was found to significantly increase the chance of making an AD by 1.87 times [ 46 ]. Conversely, reasons given by those who were unwilling to begin an ACP discussion include lack of knowledge about ACP generally [ 44 , 51 , 54 ], and of the specific content and procedures related to an AD [ 47 ]. Participants who lacked intention to prepare an AD also reported a lack of knowledge of ACP/AD [ 51 ]. Not knowing how to begin an ACP discussion was also highlighted as impeding engagement [ 54 ]. Timing Another factor that can impact participants’ willingness to begin ACP discussions and AD development was feeling it was too early to do so [ 44 , 54 ]. however, it could not be determined if this finding related to being too young or being too early in an illness trajectory. Consequently, Leong et al. [ 47 ] found that being ‘too young’ hindered ACP/AD engagement. Gender, too, was a factor relating to the timing of ACP/AD engagement, as Australian males preferred a slightly later initial ACP discussion in life than Australian females [ 49 ]. Family matters Family was found to significantly influence attitudes toward engaging in ACP/AD. This impact includes both wanting to ease the burden on their family to make such decisions [ 44 ] and preferring family members to make EOL decisions [ 51 , 54 ]. Additional factors Findings highlight various other factors that can influence the general public’s attitudes towards engaging with ACP/AD. Positive factors include self-perceived level of optimism [ 45 ], and a positive attitude towards withdrawal of futile life-sustaining treatments, active pain control, and of hospice and palliative care [ 47 , 50 ]. Participants who had past experience caring for relatives or friends with terminal illnesses were significantly more willing to complete an AD compared to those who had not (OR = 1.68, 95% CI [1.14, 2.49]) [ 47 ]. Those who would choose comfort care over active treatment, despite knowing that their time was limited and may not be extended, were more likely to complete an AD than those who chose life-prolonging treatments [ 47 ]. Factors that can hinder engagement with ACP/AD were also mentioned across the literature, such as believing they might change their minds [ 44 , 47 , 51 ], and/or feeling uncomfortable discussing ACP topics [ 51 , 54 ]. Experiences of Advance Care Planning/Advance Directive Around half of the included studies (n = 5) assessed the general public’s experiences of ACP/AD. Those who had reported experience of previous ACP discussions varied from 13% [ 54 ] to 24% of study participants [ 48 ] and the completion rate of AD ranged from 0.5% [ 45 ] to 10% [ 48 ]. Having acted in a SDM role was reported by few [ 48 ]. Advance Care Planning While the Singaporean study conducted by Ng et al. [ 54 ] reported only 13% of their sample reported having ACP discussions, the Australian studies, which had participants of a similar mean age, found that 14% and 24% of participants [ 48 , 49 ] respectively had done so. Of those who had been involved in an ACP discussion with others, in the Sellars and colleagues’ study [ 48 ], most (79%) had discussed ACP with family, had told someone about their future treatment preferences (61%), and of these around a third (30%) had documented their preferences. A larger proportion (86%) of the group who had discussed ACP reported having discussed the ACP preferences of someone else as opposed to discussing their own ACP preferences [ 48 ] which may be due to not wishing to face one’s own mortality. Advance Directive Collectively, few participants reported experience with AD. The majority of those who had heard about AD in the Chan et al. study [ 45 ] had intended to complete an AD, though very few did (0.5%). Similarly, only 20% of the Malaysian cohort [ 53 ] had thought of writing an AD, with just 6% having done so. The Sellars et al. [ 48 ] Australian study, too, found that only 10% of participants reported having completed ACP documentation (to document their future treatment preferences, to appoint an SDM, or both). In relation to AD, only the Sellars et al. [ 48 ] study reported experience of SDM with few of their sample (13%) indicating that they had enacted an SDM role and having made medical decisions on an adult’s behalf. Preferences and expectations of Advance Care Planning/Advance Directive Most of the included studies (n = 10) assessed the general public’s preferences and expectations for ACP/AD. The preferences expressed relate to: a) how best to promote and be educated about ACP, b) how to document preferences, including who should receive copies of AD, and c) the most optimal time for ACP/AD engagement. Preferences of Advance Care Planning/Advance Directive Promotion of Advance Care Planning Public promotion efforts and education, various media sources, and HCPs advocating for ACP were the most commonly reported means for promoting ACP. Online programs, setting up AD registration offices, and providing payment for ACP through a national medical insurance scheme were deemed important in the Korean study [ 51 ]. Advertisements in the media [ 54 ], including traditional and new media sources [ 48 ], receiving information from general practitioners or other HCPs advocating for ACP was noted in the Singaporean study and Australian studies, respectively [ 48 , 54 ]. Brochures on ACP, distributed by the government, was also deemed to be a preferred method of receiving information in a Korean study [ 54 ]. Advance Directive documentation Documentation of AD can be verbal, visual (video), audio (recorded), and/or written. In one study (from Malaysia), 84% preferred a verbal directive to a family member or acquaintance rather than documenting preferences, while some (67%) were open to written documentation [ 53 ]. Audio or videotape recordings of wishes was preferred by less than a quarter of this sample [ 53 ]. Participants noted they were open to giving copies of their AD to their healthcare provider and family [ 53 ]. Timing to engage in ACP/AD There are a variety of factors that need to be considered when considering the optimal timing of ACP discussions and AD completion. Those found across studies include before becoming mentally incompetent [ 46 ], when still healthy [ 50 ], when diagnosed with a life-limiting illness, such as cancer [ 50 , 53 ], when an illness progresses or reaches terminal stage [ 50 ], and prior to receiving treatments with a high mortality risk [ 51 ]. An Australian study found that 58 years was the ideal age to initiate ACP discussions [ 49 ]. Older age (≥ 65 years) and a variety of hospitalisation combinations, e.g., when patient has a severe illness and is hospitalised, were also found in one of the Korean studies to be the preferred time to engage in AD [ 51 ]. Expectations of Advance Care Planning/Advance Directive Expectations of ACP/AD included what items the general public expect to find within AD forms and their expectations of HCPs in relation to initiating such discussions, and the communication skills HCPs should possess to undertake such activities, and the realities of these expectations. Items on Advance Directive forms Life-sustaining treatment options, such as CPR and mechanical ventilation [ 50 , 53 ] and chemotherapy, as well as place of care and death [ 53 ] were items that would be expected to be found on AD forms. Most participants (91%) in the Keam et al. [ 50 ] study suggested that hospice and palliative care information should be included in AD forms. These participants also noted that clarification of treatment options is needed in such documentation. Healthcare Professionals Studies reported that the general public expect HCPs to engage in ACP conversations [ 47 , 48 ], to have good communication skills to discuss AD with patients [ 45 ], to talk directly to a patient about their situation [ 46 ], to adhere to legislation when progressing with AD documentation [ 45 ], and provide more information to help support SDMs to make decisions [ 48 ]. However, the Japanese cohort felt it too confronting to discuss AD, rather they expect a doctor to give them hope [ 52 ]. These differences in findings likely demonstrates the diversity of cultural norms across the Asia-Pacific region. Furthermore, the Australian general public [ 49 ] expected around double the input into the ACP content from clinicians than that reported by the clinicians (doctors and nurses) surveyed which suggests that their expectations do not necessarily reflect current clinical practices. DISCUSSION The perceptions of the general public towards ACP/AD in the Asia-Pacific region has not been systematically analysed. To the best of our knowledge, this is the first review to collate existing evidence of the awareness of, attitudes towards, experiences with, and expectations of ACP/AD of the general public in the Asia-Pacific region. Eleven studies met the search criteria, with most being published between 2017 and 2022. The limited number of included studies conducted in the first half of this decade may be related to the concepts of ACP/AD being in their infancy in some countries in the Asia-Pacific region [ 38 ]. This review found that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low. While they believe ACP is necessary and important, only a minority have had previous discussions regarding ACP and the low prevalence of completion of AD. Various factors were found to influence willingness to engage in ACP/AD, such as legal issues and prior awareness/knowledge. Medical professionals were expected to not only initiate ACP discussions but also to have good communication skills. Legal parameters to support ADs were also considered to be paramount. The collective findings of this review suggest that the general public of the Asia-Pacific region have limited awareness of ACP/AD. The Australian general public demonstrated a higher awareness of ACP compared to the other countries of the Asia-Pacific region represented in this review [ 48 , 49 ], which is likely due to the more advanced policy and health system acceptance of these concepts in Australia [ 55 ]. ACP/AD is a relatively new concept in the Asia-Pacific region, and there are variations in legislation regarding ACP/AD across different countries [ 38 , 56 ]. This finding aligns with a previous scoping review on the global perspective of public perception of ACP, which found that inadequate public understanding of ACP was due to widespread beliefs of misinformation, or limited access to correct information [ 18 ]. Our findings are relatively consistent with a systematic review on the opinions of older individuals on ACP [[ 57 ] that found advanced age and having a higher education degree are positively associated with ACP knowledge and awareness [ 25 ]. Our review highlighted that the sources of ACP information were primarily via the media, family and friends, and HCPs. As the general public’s lack of awareness of ACP negatively impacts their participation in ACP [ 45 , 54 ], it is important to promote ACP/AD and educate the general public about ACP using the media sources with which they are mostly likely to engage. The majority of the general public in the Asia-Pacific region countries under study agree that ACP/AD is useful and necessary [ 47 , 50 , 53 ]. This is consistent with previous systematic reviews which found those who had a positive perception of ACP agreed that ACP was necessary [ 11 ] [ 58 ]. Willingness to engage in ACP/AD were found to depend on many factors, such as age, health status, legal issues, knowledge and education, and timing. Legal considerations too, such as the AD being underpinned by legal requirements, which increase the general public’s confidence in the process and the ultimate outcomes, were found to play a significant role in the decision to engage with ACP/AD [ 44 , 46 , 47 ]. This finding is consistent with those of previous systematic reviews of ACP [ 11 , 59 ] that found diversity in legal and policy approaches to ACP across countries. The absence of a clear legal framework creates uncertainty about the legal standing of ACP and obstructs its implementation [ 11 , 59 ]. Therefore, it is necessary to establish a systematic structure that encompasses laws and policy structures to positively impact social awareness and promote ACP [ 11 ]. Despite varying rates of previous discussions regarding ACP reported across countries [ 45 , 48 , 53 , 54 ], and evidence of positive perceptions of ACP/AD [ 45 – 47 , 50 , 53 ], there was little completion of AD [ 45 , 48 , 53 ]. Previous studies have pointed out that low AD completion rates were often linked to a lack of knowledge about AD [ 60 , 61 ]. This phenomenon may be explained by the inadequate promotion of AD among the public and a lack of appetite to discuss such matters [ 60 ]. Differing cultural factors and belief systems may also impact on AD completions. Importantly, cultural values and belief systems also play a central role in shaping ACP engagement in the Asia-Pacific region. In many Asian cultures, family-based decision-making is normative, and EOL decisions are often viewed as a collective family responsibility rather than an individual act [ 58 ]. Taboos surrounding discussions of death and religious beliefs may further reduce willingness to engage in ACP or complete Ads [ 58 ]. These cultural and religious dynamics provide important contextual explanations for the low rates of ACP action observed across studies. Several studies reported that the general public expect HCPs to be their preferred source of information [ 48 ] and should possess good communication skills when discussing treatment options and EOLC (via ACP) or when completing an AD [ 45 – 47 , 49 ]. HCPs therefore need to have the necessary communication skills to discuss AD with patients and to provide them with sufficient information to support their decision-making process [ 62 ]. This result is consistent with those of a prior systematic review [ 11 ] and scoping review [ 18 ], within the global context, that the general public expect HCPs, particularly physicians, to initiate AD discussions. A previous integrative review found that there is a lack of education, training to upskill health professionals, as well as a lack of guidance for initiating and supporting them with ACP activities [ 63 ]. Therefore, public promotion efforts and education should include specific education for HCPs to ensure they are well-versed in ACP/AD topics and are skilled at initiating such discussions and to prepare AD. The challenge facing HCPs who advocate for ACP/AD is the population’s low awareness of ACP/AD and even lower numbers of persons engaging with and actioning these [ 45 , 48 , 49 , 53 , 54 ]. Even when the general public are aware of ACP/AD and believe it to be important and necessary [ 47 , 50 , 53 ], few were found to follow-up this sentiment with documenting an AD [ 45 , 48 , 53 ]. These challenges suggest that public campaigns are needed to raise public awareness through education about what ACP entails and how to document an AD. However, education alone will not be sustained without the support of the larger health and governmental systems by developing and implementing legal frameworks and public policies to address the legal and ethical barriers that may hinder the effective implementation of ACP/AD. Expectations of medical professionals to engage in ACP discussions, provide information to make decisions, and have good communication skills when discussing ACP were highlighted in the findings [ 45 – 48 ]. ACP/AD-specific education for HCPs is critical to improve their knowledge and understanding of these concepts, and to improve their communication skills in relation to such discussions. Given the significant influence of cultural and religious norms, ACP strategies in Asia–Pacific settings must also be culturally responsive, family-inclusive, and sensitive to variations in belief systems. These strategies combined are essential to create a supportive environment in which the general public will feel supported to not only discuss their future health care needs, in the event they lose their decision-making capacity, but to also complete an AD. Limitations. As with all reviews, this literature review has limitations. Firstly, due to the sensitive nature of the topic, self-selection bias of participants in the included studies is a possibility, as study participants may have had a particular interest in/experience of ACP to consent to participate. Secondly, as there are no standardised methods or tools to collect data about ACP discussions or AD completions, and most included studies did not report the reliability or validation of the instruments, the credibility of our findings is limited. Thirdly, due to the countries represented in this review our findings may not be fully generalisable to other countries in the Asia-Pacific region and elsewhere. Fourthly, while care was taken to find all relevant studies across multiple databases, it is possible that some relevant studies were not found. Our search was also limited to studies only available in English. Fifthly, our use of a narrative approach to data synthesis involved an interpretive, and hence subjective, process that may have impacted the accuracy and transparency of our findings. Even so, data were extracted by two authors independently and the review team discussed the categorised and collated findings on a number of occasions to identify and refine themes. Conclusion This review highlights that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low. Although people across this region recognise the usefulness and necessity of ACP/AD, only a small percentage had actioned these. There are various factors influencing people's willingness to engage in ACP/AD, such as legal issues and prior awareness/knowledge which need to be researched further and addressed, particularly across the various cultural contexts. Findings revealed that the general public expect medical professionals to have good communication skills when discussing ACP as that they would like ADs to be supported by legal parameters to protect patient autonomy and to facilitate their contribution to their EOL treatment. HCPs initiating ACP discussions, together with both legal and policy support for ACP/AD, were identified as the most important means for facilitating higher levels of awareness and activation of ACP/AD processes. Therefore, it is important to first get ACP/AD on policy agendas and to raise the general public’s awareness of ACP via promotion campaigns and by providing freely available ACP education to debunk negative perceptions of ACP/AD. Such initiatives would benefit patients (by having their wishes documented and respected, such as dying at their preferred place), family members (due to reduced burden when decisions need to be made), HCPs (knowing the patient’s and their family’s EOL treatment decisions), and systems (through fewer inappropriate hospitalisations and more appropriate use of resources). Further research is needed to underpin multimodal strategic approaches and to inform the development of culturally appropriate education interventions to be implemented at a population level. Abbreviations ACP Advance Care Planning AD Advance Directive CI Confidence Interval EOL End–of–Life EOLC End–of–life Care EPA Enduring Power of Attorney HCPs Healthcare Professionals MMAT Mixed Methods Appraisal Tool OR Odds Ration SAR Special Administrative Regions SDM Substitute Decision Making Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Corresponding author Correspondence to Piyawan Pokpalagon Funding The author (s) received no specific funding for this work. PP has received scholarship support from Faculty of Medicine Ramathibodi Hospital, Mahidol University, to support her work as a Postdoctoral Research Fellow and for publication purposes. Author Contribution Project administration: PP; Conceptualisation of review protocol and search strategy: PP, SC, PY; Abstract/full text screening, data extraction and analysis: PP, SC, GS; Interpretation of findings: PP, SC, GS, PY; Manuscript writing and editing: PP, SC, GS, PY. Acknowledgement The lead author would like to express gratitude to the Faculty of Health, School of Nursing at Queensland University of Technology (QUT) for accepting her as a Visiting Postdoctoral Research Fellow and to Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University for scholarship support. Additionally, the lead author wishes to sincerely thank her supervisors, PY and SC, for their guidance, invaluable advice, and kind support. Special thanks are also extended to GS for all contributions, and to the QUT health liaison librarian for assisting in the search strategy. Data Availability The data used for this review were extracted from publicly available journals. The Excel file in which we stored the extracted data is available upon reasonable request. References Ageing and health. [ https://www.who.int/news-room/fact-sheets/detail/ageing-and-health] World Health Organization. Decade of healthy ageing: baseline report. 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The development and validation of the advance care planning questionnaire in Malaysia. BMC Med Ethics. 2016;17(1):61. Additional Declarations No competing interests reported. Supplementary Files ACPSystematicReviewAdditionalFile.docx ACPSystematicReviewAdditionalFile30Sep2025.docx Cite Share Download PDF Status: Published Journal Publication published 23 Apr, 2026 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 05 Oct, 2025 Submission checks completed at journal 01 Oct, 2025 First submitted to journal 29 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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This challenge is particularly relevant to the Asia-Pacific region, which encompasses the South-East Asian Region and the Western Pacific Region totalling 48 countries, areas, and territories [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These regions combined have experienced an accelerated pace of population aging, with a higher percentage of populations aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years compared to other global regions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. As populations age, the prevalence of noncommunicable diseases (NCDs) continues to rise, resulting in individuals living longer with multiple chronic conditions and increasing care complexity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite improvements in detection and therapies, NCDs remain the leading causes of mortality and contribute to substantial health-related suffering due to persistent symptom burden and frequent hospitalisations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Global projections indicated that health related suffering will continue to increase with the largest rise expected in low-income countries and among adults aged\u0026thinsp;\u0026ge;\u0026thinsp;70 years [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This increase will be driven by a higher incidence and prevalence of cancers and dementia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; almost 50% of the people with dementia worldwide will reside in the Asia-Pacific region [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The convergence of rapid demographic transition and escalating NCD prevalence highlights the increased and ongoing need to plan end-of-life care (EOLC).\u003c/p\u003e \u003cp\u003eOne approach to increase EOLC planning is via Advance Care Planning (ACP) which is a process that \u0026ldquo;enables individuals to identify their values, to reflect upon the meanings and consequences of serious illness scenarios, to define goals and preferences for future medical treatment and care, and to discuss these with family members and healthcare professionals (HCPs)\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] (p. e546). Advance care planning has been found to result in many benefits for patients, their family carers, and healthcare systems, such as enabling patients to die in their preferred place [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], reduced decision-making burden on family [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and reduced lengths of hospital stays which reduces costs to the healthcare system [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Advance care planning may lead to the completion of an Advance Directive (AD), a legal document that provide instructions for medical care on behalf of the patient, in the event the patient is incapable of making their own decisions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The AD, which is also referred to as a living will by some, may also detail a substitute decision-maker (SDM) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the well-documented benefits of participating in ACP and completing an AD [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], many members of the general public have been found to have negative or unclear perceptions of ACP/AD [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], which could be mitigated by population-level health behaviour interventions such as public messaging [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This is especially relevant to the Asia-Pacific region, as the implementation of ACP/AD programs for the general public in the community could play an essential role in helping individuals prepare for the EOLC they prefer. Therefore, it is important to understand the level of the public\u0026rsquo;s awareness of ACP/AD, their perceptions of and perspectives on this topic, and to identify what information and support would be most beneficial in encouraging the general public to consider ACP/AD.\u003c/p\u003e \u003cp\u003eHowever, the majority of reported studies, which explore the perceptions and perspectives towards ACP/AD, are undertaken from the perspective of patients with life-limiting illnesses [\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], older adults [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], their carers [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], and HCPs [\u003cspan additionalcitationids=\"CR29 CR30 CR31\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Recent scoping reviews exploring the general public\u0026rsquo;s perceptions of ACP from an international perspective demonstrated poor public knowledge of ACP and its purpose and scope, and a general reluctance to name a proxy-decision maker or complete a written AD [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A systematic review which investigated issues surrounding ACP discussions within an East Asian context found a general lack of understanding and knowledge amongst members of the community as well as a lack of awareness of decision-making rights [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. However, the experience of ACP in the Asia-Pacific region may differ due to various cultural values that may affect the general public\u0026rsquo;s perception, attitudes, experiences and expectations of ACP; this can directly impact engagement with ACP [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current literature demonstrates that the public\u0026rsquo;s perception towards ACP/AD in the Asia-Pacific region has not been systematically analysed. To address this gap, this review aimed to identify and explore studies that report the general public\u0026rsquo;s perceptions of ACP and AD and to provide an evidence base to inform future interventions that aim to increase the general public\u0026rsquo;s awareness and acceptance of ACP and AD within the Asia-Pacific region.\u003c/p\u003e \u003cp\u003eThe objectives of this review are, within the context of the Asia-Pacific region, to:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eexplore the general public\u0026rsquo;s awareness of ACP/AD\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eexplore the attitudes of the general public towards ACP/AD\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eexplore the general public\u0026rsquo;s experiences of ACP/AD; and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eidentify and explore the needs, wishes, and/or expectations of the general public related to ACP/AD.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023491109). The review is reported against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria:\u003c/h2\u003e \u003cp\u003eThe study selection criteria were pre-determined by the Population, Interest, and Context (PICO) framework [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] for this review. Primary studies of any design reporting awareness, attitudes, experience, and expectations regarding ACP of the general adults (aged\u0026thinsp;\u0026ge;\u0026thinsp;18) public were included. Only studies with full texts available in English, conducted in the Asia-Pacific region, and published between 2013, the year in which amendments to the Natural Death Act and related policy reforms in several Asian countries [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] were made, and 2023 were considered. Studies that only report the perspectives of HCPs, a specific age group of individuals, patients with life-limiting illnesses and their caregivers, or fail to separately report findings relating to the adult general public, were excluded. Furthermore, literature reviews, non-published higher degree dissertations and theses, conference abstracts, single case studies, editorials, commentaries, discussion and opinion pieces, guidelines, and other non-research pieces, and non-peer-reviewed articles were excluded.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch strategy:\u003c/h3\u003e\n\u003cp\u003ePreliminary searches were conducted in PubMed to identify keywords and terms that align with the review question. The authors then developed a systematic search strategy in PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO (EBSCOhost), Embase, and Emcare (via OVID) databases; searches were completed 7 November 2023. Tailored search terms were used for each database, using thesaurus terms (Emtree and MeSH) where applicable (see Additional file 1, Table A1).\u003c/p\u003e\n\u003ch3\u003eStudy selection:\u003c/h3\u003e\n\u003cp\u003eDuplicate records were removed using automated processes in Endnote (Version X9; 2013) [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] with the help of a university librarian and the web-based application \"Rayyan QCRI\" (artificial intelligence) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], as well as manually. In Rayyan, the title/abstract of the remaining records were screened against the selection criteria for eligibility by two authors independently; one author (PP) reviewed all abstracts and two authors (SC and GS) reviewed an equal portion each. Disagreements on selection were discussed between the two authors; when consensus was not reached, the record was kept for full-text review.\u003c/p\u003e \u003cp\u003eThe full text of the selected publications was assessed for eligibility independently by two authors using the same division of tasks as per abstract/title screening. Unresolved disagreements were to be discussed with a third independent author (PY), however the need did not arise. Reasons for rejection were recorded.\u003c/p\u003e\n\u003ch3\u003eData extraction and synthesis:\u003c/h3\u003e\n\u003cp\u003eA tailored data extraction Excel spreadsheet was developed (see Additional File, Table A2 for details) and pilot tested by two authors (PP and SC). After refinement, data were extracted from each included study by two authors independently, as per the method used for title/abstract screening. Extracted data were compared and discussed and relevant appropriate adjustments made. A meta-analysis of findings was not possible due to the heterogeneity of outcome measures and most surveys used were not validated. Hence, a narrative synthesis approach, which has been found to be well-suited to synthesising evidence [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], was used to collate and group data. This synthesis was underpinned by Cochrane methods [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Categorisation of the included studies\u0026rsquo; findings was undertaken upon consensus amongst the review authors.\u003c/p\u003e\n\u003ch3\u003eQuality Appraisal and Risk of Bias:\u003c/h3\u003e\n\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe Mixed Methods Appraisal Tool (MMAT, Version 2018) [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] was used to appraise the overall methodological quality of included studies as no study design, other than single case studies, was excluded from this review. This tool [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] assesses five methodological criteria as relevant for different types of study designs. Each included study (publication) was independently appraised for methodological quality by two authors using the same method of distribution as per title/abstract screening. Studies were not excluded due to low methodological quality, rather the overall quality of the studies was of interest. No score of quality was calculated as this is discouraged by the MMAT developers [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, to gain a sense of quality across studies, they were classified based on the number of criteria met (as agreed upon by two authors) with studies meeting four (80%) or five (100%) criteria considered high quality, those meeting two (40%) or three (60%) criteria considered medium quality, and those meeting only one (20%) or none (0%) considered low quality.\u003c/p\u003e \u003cp\u003eRisk of bias was further addressed through transparent and rigorous review procedures. The search strategy was developed with input from a world-class expert in the field (PY) and a university health librarian, and a variety of reputable academic databases were searched. These processes ensured a broad range of studies would be included. Furthermore, the review protocol was prospectively registered with PROSPERO and reference lists of included studies were examined for additional eligible studies.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStudy selection\u003c/h2\u003e \u003cp\u003eLiterature searches yielded 3105 records. After duplicates were removed, the screening of 2325 abstracts resulted in 95 records retained for full text review. From these, 84 articles were excluded with most due to not focusing on the general public (see Fig.\u0026nbsp;1 for details). Ultimately, 11 studies met the inclusion criteria and were included in the final review. The study characteristics of the included studies are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary Table: Main characteristics and limitations of included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"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=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor/Year/ Country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAim/s\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMethods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eQuestionnaire\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMMAT\u003csup\u003e1\u003c/sup\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChan et al., 2019\u003c/p\u003e \u003cp\u003eHong Kong SAR (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo examine prevalence, perception, and predictors of AD completion in the Hong Kong general population with a diverse culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Population-based cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRandom sampling; Phone survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;2002 Hong Kong general population aged\u0026thinsp;\u0026ge;\u0026thinsp;18 who communicate in Chinese (response rate: 42.8%; cooperation rate: 43.7%)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026ge;45 years 58.6%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 55.8%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: None 78.9%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: Senior secondary or higher 70.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- Developed by research team, Five-part questionnaire includes: 1) socio-demographic characteristics, 7 items; 2) self-perception and health status, 6 items; 3) the prevalence of AD, 2 items; 4) perceptions related to AD, 8 items; 5) making AD in various scenarios, 7 items.\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Cronbach's alpha 0.81\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Study's cross-sectional nature hampers identifying causal relationships between predictors and AD completion.\u003c/p\u003e \u003cp\u003e- Use of phone interviews may have excluded eligible participants without a phone \u0026ndash; sampling bias.\u003c/p\u003e \u003cp\u003e- Low response rate may have introduced bias.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChung et al., 2017\u003c/p\u003e \u003cp\u003eHong Kong SAR (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo describe knowledge, attitudes, and preferences of the general Hong Kong adult population across different age groups regarding EOLC decisions, place of care and death, as well as AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Population-based cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRandom sampling; Phone survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1067 Hong Kong Chinese residents aged\u0026thinsp;\u0026ge;\u0026thinsp;30 years who spoke Cantonese\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026ge; 40 years 88.5%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 62.7%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: None 69.6%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: Secondary or higher 68.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFormulated by research team to obtain information regarding knowledge, attitudes, and/or preferences toward advance decisions and EOLC\u003c/p\u003e \u003cp\u003e- \u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e- \u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Caution needed when inferring causal relationships between predictors and outcomes due to study design.\u003c/p\u003e \u003cp\u003e- Those without a phone may differ from the general public \u0026ndash; sampling bias.\u003c/p\u003e \u003cp\u003e- Phone interviews were time-constrained, thus can potentially affect accuracy of responses.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroenewoud et al., 2020\u003c/p\u003e \u003cp\u003eJapan \u0026amp; Netherlands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo compare Dutch and Japanese general public\u0026rsquo;s attitudes and preferences toward EOLC, and EOL decisions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- Quantitative: Cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuota sampling strategy by age, gender, and living areas - random sampling strategy \u0026ndash; sent emails; Online survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1038 Japanese general public aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1040 Dutch general public aged\u0026thinsp;\u0026ge;\u0026thinsp;20 years (\u003cem\u003eNote\u003c/em\u003e: only findings of the Japanese general public used in this review)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026ge;40 years 80%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 50%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: N/A\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: Moderate to High academic 80.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- No details of the questionnaire used in this study were provided in this paper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Small sample size did not allow for sub-analyses on regional variation.\u003c/p\u003e \u003cp\u003e- Using quota sampling method did not result in a representative sample for age, urbanisation, education, and income.\u003c/p\u003e \u003cp\u003e- Using a panel, rather than recruiting respondents from the public by hand, may have biased the results.\u003c/p\u003e \u003cp\u003e- Multiple comparisons were not adjusted for due to the exploratory nature of the study.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeam et al., 2013\u003c/p\u003e \u003cp\u003eKorea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- To investigate Korean attitudes toward AD among cancer patients, family caregivers, oncologists, and the general public.\u003c/p\u003e \u003cp\u003e- To identify factors associated with a favourable perception toward AD\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Multicentre\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- Phone interview survey with structured questionnaire for general public, conducted by professional interviewer\u003c/p\u003e \u003cp\u003e- In-person survey for patients, family caregivers, and oncologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1006 Korean general public aged 20\u0026ndash;70 years\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1242 cancer patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1289 family caregivers\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;303 oncologists (\u003cem\u003eNote\u003c/em\u003e: only general public findings used in this review)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026ge;40 years 52%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Male 50.4%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: No religion 37.4%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: College or higher 49.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- Structured questionnaire developed by researchers, which includes:\u003c/p\u003e \u003cp\u003e1) Demographic details\u003c/p\u003e \u003cp\u003e2) Necessity of AD\u003c/p\u003e \u003cp\u003e3) Optimal timing of AD\u003c/p\u003e \u003cp\u003e4) Necessary items for AD form\u003c/p\u003e \u003cp\u003e5) Disclosure of terminal status, HPC, withdrawal of futile life-sustaining treatment, \u0026amp; euthanasia.\u003c/p\u003e \u003cp\u003e- \u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e- \u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- The survey was conducted by phone with the general public, which differs from the data collection method used with other participants.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeong et al., 2021\u003c/p\u003e \u003cp\u003eMacao\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo explore Macao Chinese residents\u0026rsquo; willingness to make ADs, and to identify predictors of their willingness to make ADs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-probability quota sampling by age; Online survey and face-to-face interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;724 Macao residents aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years (completion rate 72.3%)\u003c/p\u003e \u003cp\u003e86.2% were self-administered online\u003c/p\u003e \u003cp\u003e13.8% were completed face-to-face by interviewers\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026ge;40 years 57.9%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 64.9%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: No religion 57.7%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: College or higher 57.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStructured questionnaire, written in Chinese by research team: 4 sections: 1) Sociodemographic profile; 2) Self-rated health; 3) Preferences of EOL treatment and attitudes towards EOLC; 4) Willingness to make AD.\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003eThe Hospice Care Attitude Scale assessed participants\u0026rsquo; attitudes towards EOLC.\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Cronbach\u0026rsquo;s coefficient 0.79; test-retest reliability 0.94.\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Item\u0026ndash;Content Validity Index\u0026thinsp;=\u0026thinsp;1.00; good level of Construct Validity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Limited representativeness - non-probabilistic quota sampling to match age distribution of participants with Macao population\u003c/p\u003e \u003cp\u003e- Self-selection bias \u0026ndash; those who consented may reflect positive attitudes towards EOLC issues.\u003c/p\u003e \u003cp\u003e- Potential bias due to using both online and face-to-face interviews; primarily collecting data from online surveys.\u003c/p\u003e \u003cp\u003e- Potential bias due to the higher education and professional occupations of participants.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLim et al., 2022\u003c/p\u003e \u003cp\u003eMalaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo assess knowledge, attitudes and practice (KAP) among community-dwelling adults in Malaysia regarding ACP, and its associated factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Cross-sectional-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFace-to-face interviews undertaken by trained researcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;385 community-dwelling adults (response rate 98%).\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: Median 61 years\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 55.8%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: Islam 38.4%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: Secondary or higher 85.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- English or Malay ACPQ, 4 domains:\u003c/p\u003e \u003cp\u003e1) Demographics\u003c/p\u003e \u003cp\u003e2) Knowledge\u003c/p\u003e \u003cp\u003e3) Attitude\u003c/p\u003e \u003cp\u003e4) Practice of ACP.\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Cronbach\u0026rsquo;s alpha values for items in each domain range:0.637\u0026ndash;0.915. In test-retest, kappa values range: 0.738\u0026ndash;0.947 [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Factor analysis of 22 items revealed 4 domains and found to be valid instrument\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Recruitment of community-dwelling adults from a single site - may have affected the generalisability of this study.\u003c/p\u003e \u003cp\u003e- Acquiescence bias as a result of interviewer-assisted questionnaires is possible.\u003c/p\u003e \u003cp\u003e- Testing knowledge was not possible because of the limited awareness.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNg et al., 2017\u003c/p\u003e \u003cp\u003eSingapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- To investigate awareness of local Singapore community towards ACP\u003c/p\u003e \u003cp\u003e- To ascertain their willingness to engage in ACP discussions\u003c/p\u003e\u003cp\u003e- To identify factors that affect an individual\u0026rsquo;s willingness to participate in ACP\u003c/p\u003e\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative:\u003c/p\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTwo-stage stratified random sampling; face-to-face interviewer-lead survey by trained fourth-year medical students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;406 community dwellers of Housing and Development Board flats (completion rate 23.37%)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: Mean 46.8\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 53.1%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: Buddhism 23.4%, No religion 22.7%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: Secondary or higher 84.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- Researchers developed 23 close-ended questions that evaluated respondents\u0026rsquo; awareness and knowledge of ACP, willingness to engage in ACP, and factors influencing willingness to undergo an ACP discussion.\u003c/p\u003e \u003cp\u003e- Questionnaire was developed in English and translated to Chinese.\u003c/p\u003e \u003cp\u003e- Questionnaire was pilot tested with n\u0026thinsp;=\u0026thinsp;40 randomly selected community-dwelling individuals and refined\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Participation bias \u0026ndash; residents who were non-English or non-Mandarin speaking or living in private estates were excluded.\u003c/p\u003e \u003cp\u003e- Poor response rate\u003c/p\u003e \u003cp\u003e- Self-selection bias: survey participates may be more receptive to talking about EOL issues than those who declined.\u003c/p\u003e \u003cp\u003e- Social desirability may have influenced respondents\u0026rsquo; willingness to engage in an ACP discussion after education.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNi et al., 2021\u003c/p\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmong Chinese adults:\u003c/p\u003e \u003cp\u003e- To describe knowledge and attitudes of AD and EOLC preferences\u003c/p\u003e \u003cp\u003e- To explore factors related to preferences for AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative:\u003c/p\u003e \u003cp\u003eCross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnline survey through a link in a short phone text message\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1114 Chinese residents aged\u0026thinsp;\u0026ge;\u0026thinsp;18\u0026thinsp;years living in Wuhan\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: Mean 48.03\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 65.3%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: No religious 90.3%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: Associate degree or higher 68.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKnowledge and preferences for AD and EOL care assessed using a tool designed for older Chinese adults which has been used with nursing home residents in Hong Kong and Wuhan\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Sampling bias due to individuals being registered in 8 household management centres in Wuhan and due to self-selection bias.\u003c/p\u003e \u003cp\u003e- Generalisation of findings to China\u0026rsquo;s population is not guaranteed.\u003c/p\u003e \u003cp\u003e- Only residents with smartphones could access survey, excluding opinions of those without a smartphone.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePark et al., 2019\u003c/p\u003e \u003cp\u003eSouth Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo investigate awareness and attitudes towards ACP in South Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Multicentre (nationwide) cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- Phone survey of general public\u003c/p\u003e \u003cp\u003e- Face-to-face survey for cancer patients and family caregivers\u003c/p\u003e \u003cp\u003e- Online survey for physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1005 general public aged 20\u0026ndash;70 years\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1001 cancer patients\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1006 Family caregivers\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;928 Physicians \u003cem\u003e(Note\u003c/em\u003e: only general public findings used in this review)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026gt;50 years 42.8%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 50.8%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: No Religious 58.2%\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: High school or higher 63.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- Structured questionnaire developed by researchers, which includes:\u003c/p\u003e \u003cp\u003e1) Awareness of ACP\u003c/p\u003e \u003cp\u003e2) Willingness to conduct ACP\u003c/p\u003e \u003cp\u003e3) Suitable timing to write an AD\u003c/p\u003e \u003cp\u003e4) Strategies to facilitate ACP\u003c/p\u003e \u003cp\u003e5)Sociodemographic details\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- The questionnaire focused on hypothetical scenarios, therefore attitudes and behaviours when faced with a real situation could be different.\u003c/p\u003e \u003cp\u003e- The Korean healthcare system and policy regarding ACP could influence results.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSellars et al., 2021\u003c/p\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo describe the Australian adult public\u0026rsquo;s knowledge and experiences regarding SDM for medical decisions and their preferences for obtaining information about the SDM role\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: National cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdults who voluntarily signed up to a recruitment agency register (Dynata) were invited to complete survey; Online survey via the company\u0026rsquo;s website\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1120 Australian adults aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years residing in Australia at the time of the study (completion rate 70.6%)\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: \u0026ge;40 years 64.3%\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Female 55.3%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: No religion 37.5%\u003c/p\u003e \u003cp\u003eEducation: Senior secondary or higher 89.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe survey was developed by a research team and refined after a pilot with 14 adult Australians to assess question comprehension\u003c/p\u003e \u003cp\u003eThe survey comprised:\u003c/p\u003e \u003cp\u003e1) Demographic information\u003c/p\u003e \u003cp\u003e2) Knowledge: ACP and SDM\u003c/p\u003e \u003cp\u003e3) Attitudes: SDM\u003c/p\u003e \u003cp\u003e4) Needs, concerns, and intentions: SDM\u003c/p\u003e \u003cp\u003e5) Resource development\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- More women than men responded to survey.\u003c/p\u003e \u003cp\u003e- Participants were not totally representative as they were older than the available estimates for the Australian public overall.\u003c/p\u003e \u003cp\u003e- Due to the opt-in sampling methodology, the generalisability of findings may be limited.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhyte et al., 2022\u003c/p\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo explore cognitive and behavioural biases that influence individual\u0026rsquo;s\u003c/p\u003e \u003cp\u003ewillingness to engage ACP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuantitative: Cross-sectional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- General public recruited via a commercial research company\u003c/p\u003e \u003cp\u003e- Online survey\u003c/p\u003e \u003cp\u003e- In person survey for healthcare professional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en\u003c/b\u003e\u0026thinsp;=\u0026thinsp;1248 Australian adults aged 18\u0026ndash;80 years\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;117 HCPs recruited from conference attendees of the General Practice Conference and Exhibition\u003c/p\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: Mean 41.3 years\u003c/p\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e: Male 45.5%\u003c/p\u003e \u003cp\u003e\u003cb\u003eReligious\u003c/b\u003e: N/A\u003c/p\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e: N/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e- Topic covered:\u003c/p\u003e \u003cp\u003e1) Demographics\u003c/p\u003e \u003cp\u003e2) Preference for ACP decision-making\u003c/p\u003e \u003cp\u003e3) Cognitive bias tests (6 items)\u003c/p\u003e \u003cp\u003e4) Personal experience with ACP (3 items)\u003c/p\u003e \u003cp\u003e\u003cb\u003eReliability\u003c/b\u003e: Not reported\u003c/p\u003e \u003cp\u003e\u003cb\u003eValidity\u003c/b\u003e: Not reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e- Generalisability may be impacted by convenience sampling method.\u003c/p\u003e \u003cp\u003e- Study does not account for potential patient cognitive impairment, which is often the catalyst for initiating ACP discussions and processes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eACP - Advance Care Planning, ACPQ - ACP Questionnaire, AD - Advance Directive, DNACPR - Do Not Attempt Cardiopulmonary Resuscitation, EOL \u0026ndash; End-of-Life, EOLC \u0026ndash; End-of-life Care, EPA - Enduring Power of Attorney, HCPs \u0026ndash; Healthcare Professionals, HPC - Hospice\u0026ndash;Palliative Care, KAP - Knowledge, Attitude and Practice, SDM - Substitute Decision Making\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePlace Fig. 1. here\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eFigure 1.\u003c/b\u003e The PRISMA flow diagram\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePlace Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eQuality appraisal\u003c/h2\u003e \u003cp\u003eAll included studies were of a quantitative descriptive design therefore were appraised as per the criteria set out in the MMAT for this study design type, which includes: (1) relevance of the sampling strategy, (2) representativeness of the sample, (3) appropriateness of measurements, (4) risk of nonresponse bias, and (5) appropriateness of statistical analyses. Two authors agreed all but one study met four (n\u0026thinsp;=\u0026thinsp;5 studies) or three (n\u0026thinsp;=\u0026thinsp;5 studies) of the five appraisal criteria, hence 91% of included studies (n\u0026thinsp;=\u0026thinsp;10) were considered to be of medium to high quality. Only one study was considered to be of low quality. The \u0026lsquo;risk of nonresponse bias\u0026rsquo; was the most common criterion that was appraised as either not able to be determined (n\u0026thinsp;=\u0026thinsp;6 studies) or not being met (n\u0026thinsp;=\u0026thinsp;1 study). Appropriateness of statistical analysis\u0026rsquo; methods was agreed on by both authors across all included studies (See Additional file 1, Table A3 for full details).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of included studies:\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eCountry and date\u003c/h2\u003e \u003cp\u003eSix countries in the Asia-Pacific region are represented in this review. Four of the included studies were conducted in China or from Special Administrative Regions (SAR) of China, which includes one from China [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], two from the Hong Kong SAR [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], and one from Macao SAR [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Two studies were conducted in Australia [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], two in the Republic of Korea [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e] and one study also originated from Japan [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], Malaysia [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and Singapore [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Although searches were conducted from 2013, most of the included studies (n\u0026thinsp;=\u0026thinsp;10) were conducted between 2017 and 2022 [\u003cspan additionalcitationids=\"CR45 CR46 CR47 CR48\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR52 CR53\" citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSample characteristics\u003c/h2\u003e \u003cp\u003eAll participates in the included studies were considered to be adults (aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years) however the inclusion criterion for minimum age of studies varied with the age of some samples starting at 20 years [\u003cspan additionalcitationids=\"CR51\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], 21 years [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and from 30 years of age [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. We are unable to report a collective mean age of participants across studies as some only reported against age groupings, e.g., 45\u0026ndash;65 years. Most studies had similar ratios of male and female participants (female 50\u0026ndash;65%). Study participants had, primarily, moderate to high levels of education (secondary school, college, and higher), and most reported having no religious beliefs. Sample sizes of the included studies ranged from 385 to 2002 with most studies (n\u0026thinsp;=\u0026thinsp;8) having samples of over 1000 participants [\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49 CR50 CR51\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for all study characteristics.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStudies\u0026rsquo; design and data collection methods\u003c/h2\u003e \u003cp\u003eAll included studies were of a quantitative, cross-sectional design. All but one of the included studies investigated ACP as part of broader structured questionnaires that also sought data on awareness and attitudes towards, experiences with, and preference for ACP/AD; one study did not mention the questionnaire used in the study [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Surveys were completed by telephone [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], online [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e], face-to-face [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and both online and face-to-face [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Not all surveys used across the studies were validated. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e for validation details.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eOverview of main findings:\u003c/h2\u003e \u003cp\u003eFindings were broadly categorised into four main groupings that align with the review\u0026rsquo;s objectives, the general public\u0026rsquo;s: awareness of; attitudes towards; experiences with; and needs, wishes, and/or expectations of ACP/AD. (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e for brief overview, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e for details of findings, and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for themes and sub-themes of findings).\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\u003eIncluded papers reporting on the outcomes of interest\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\u003eAuthor/Year/Country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttitudes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpectations\u003c/p\u003e \u003cp\u003e/Preferences\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChan et al, 2019; Hong Kong SAR (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChung et al, 2017; Hong Kong SAR (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroenewoud et al, 2020; Japan \u0026amp; Netherlands\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeam et al, 2013; Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeong et al, 2021; Macao (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLim et al, 2022; Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNg et al, 2017; Singapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNi et al, 2021; China\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePark et al, 2019; South Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSellars et al, 2021; Australia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhyte et al, 2022; Australia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026radic;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Studies Reporting Outcomes of Interest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e9\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"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\u003eSummary table: Awareness, attitudes, experiences, and expectations of ACP/AD in Asia-Pacific region\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\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAuthor/Year/\u003c/p\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttitudes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExpectations/ Preferences\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChan et al., 2019\u003c/p\u003e \u003cp\u003eHong Kong SAR (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;368 (18.4%) had heard about AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;1629 (81.4%) had not heard of an AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;5 (0.2%) cannot remember if head about AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- 82.1% AD is a basic human right.\u003c/p\u003e \u003cp\u003e- 72.7% promotion on AD in community adequate.\u003c/p\u003e \u003cp\u003e- 77.8% patients should have a clear mind and be mentally prepared when considering making AD.\u003c/p\u003e \u003cp\u003e- 77.5% HCPs should have good communication skills when discussing making AD with patients.\u003c/p\u003e \u003cp\u003e- 71.8% family members of patient should engage in discussing making AD.\u003c/p\u003e \u003cp\u003e- \u0026lsquo;Variables: Employment status\u0026rsquo;, \u0026lsquo;religion\u0026rsquo;, \u0026lsquo;self-perceived level of optimism\u0026rsquo;, and \u0026lsquo;level of agreement that patients\u0026rsquo; will and decisions\u0026rsquo; should be respected were significantly and independently associated with the level of acceptance on AD completion.\u003c/p\u003e \u003cp\u003e- Compared with the employed, students were significantly associated with a lower level of acceptance (B: -5.89, SE: 1.41, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e- With reference to those without any religion, a higher degree of AD acceptance was significantly associated with Christianity (B: 5.12, SE: 1.32, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Catholicism (B: 4.78, SE: 2.37, p\u0026thinsp;=\u0026thinsp;0.044), and Buddhism (B: 8.19, SE: 1.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e- Compared with participants perceiving themselves as pessimistic, increasing levels of acceptance on AD completion were found among those who were becoming more optimistic (B ranged from 4.32 to 9.49, all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e- A higher level of agreement by participants on the statement that patients\u0026rsquo; wishes and decisions should be respected was found to be associated with a higher the level of acceptance on AD completion, when compared with those that disagreed with the statement (B ranging from 6.22 to 20.11, all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;11 (0.5%) Had an AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;357 (17.8%) Did not have an AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;295 (14.7%) Had made AD or intend to make AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFor the discussion of AD:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;1,558 (77.8%) Patients should have a clear mind and be mentally prepared when considering making an AD.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;1,515 (75.7%) HCPs should possess good communication skills when discussing making an AD with patients.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;1,439 (71.8%) Family members of the patient should be engaged in discussions for making an AD.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChung et al., 2017\u003c/p\u003e \u003cp\u003eHong Kong SAR (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;153 (14.3%) had heard of AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;333 (31.2%) had heard of DNACPR\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;103, (9.7%) had heard of EPA\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;215 (64.60%) knew what DNACP and n\u0026thinsp;=\u0026thinsp;52 (50.5%) knew what EPA were (among those who had heard of types of advance decisions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;788 (73.9%) agreed it was a good approach to make an AD before they became mentally incompetent (after explaining about AD).\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;650 (60.9%) would make an AD if AD were legislated\u003c/p\u003e \u003cp\u003e- Would not make an AD due to:\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;127 (52.7%) possibility of changing their mind\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;33 (13.7%) being inconvenient/troublesome to do so\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;28 (11.6%) being afraid of being deprived of desired/needed care\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;62(25.7%) other reasons\u003c/p\u003e \u003cp\u003e- Being a female participant significantly reduced the chance of making an AD by 1.30 times.\u003c/p\u003e \u003cp\u003e- Having prior knowledge of DNACPR significantly increased the chance of making an AD by 1.87 times.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;920 (86.2%) agreed that patients\u0026rsquo; own wishes should determine what treatment they should receive.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;984 (92.2%) believed that it is a good practice for medical staff to talk to patients directly about their situation and EOL care.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;931 (87.6%) indicated that they would prefer to receive appropriate palliative care that gives comfort even though it may not prolong life.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;132 (12.4%) chose to prolong their lives with medical interventions for as long as possible.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroenewoud et al., 2020\u003c/p\u003e \u003cp\u003eJapan (\u0026amp; The Netherlands \u0026ndash; note only results from Japanese reported here)\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\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;676 (65.1% of Japanese cohort) reported that they would be happy for doctors to pro-activity confront them with their future death, and talk with them about goals in life done in ACP\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;191 (18.4% of Japanese cohort) reported that ACP is too confronting and that they would expect a doctor to give them hope\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeam et al., 2013\u003c/p\u003e \u003cp\u003eKorea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;934 (94.9%) of general public agreed with the necessity of AD\u003c/p\u003e \u003cp\u003e- Optimal timing for completing AD:\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;335 (33.9%) When cancer diagnosed\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;313 (31.7%) When in terminal status\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;26 (27%) When Healthy\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;73 (7.4%) When death is Impeding\u003c/p\u003e \u003cp\u003e- Age, education, attitude toward terminal illness, and attitudes toward hospice-pall care found to be significantly associated with attitudes to AD (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e- Younger age (p\u0026thinsp;=\u0026thinsp;0.006), higher education (p\u0026thinsp;=\u0026thinsp;0.002), agreement with the disclosure of terminal illness (p\u0026thinsp;=\u0026thinsp;0.001), a positive attitude toward the withdrawal of futile life-sustaining treatment (p\u0026thinsp;=\u0026thinsp;0.003), a positive attitude toward active pain control in terminal cancer patients (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a positive attitude towards hospice and palliative care (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were found to be independently associated with the necessity of AD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGeneral public\u0026rsquo;s preferences of necessary items in AD form:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;880 (90.8%) Explanation for Hospice and Palliative Care\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;786 (81.5%) CPR\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;793 (81.7%) Artificial Nutrition and Hydration\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;776 (80.7%) Antibiotics use\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;742 (77.8%) Haemodialysis\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;758 (77.2%) Mechanical ventilator:\u003c/p\u003e \u003cp\u003e# Chi-square P\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeong et al., 2021\u003c/p\u003e \u003cp\u003eMacao (China)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;533 (73.6%) would complete an AD if document was recognised legally.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;50 (6.9%) would \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003enot\u003c/span\u003e complete an AD.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;141 (19.5%) did \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003enot know or were undecided\u003c/span\u003e about completing an AD.\u003c/p\u003e \u003cp\u003e- \u003cb\u003eTop three reasons of those unwilling to set up AD\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;104 (54.5%) did not know the specific content of AD\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;81 (42.4%) did not know the procedures of setting up AD\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;79 (41.4%) afraid that they might change their mind after setting up AD\u003c/p\u003e \u003cp\u003e- \u003cb\u003ePredictors of willingness to make AD\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e\u0026bull; Age, educational level, marital status, average monthly income in the past year, caring experiences, EOL treatment option, and the score of the Hospice Care Attitude Scale were found to be significantly correlated with willingness to make AD.\u003c/p\u003e \u003cp\u003e\u0026bull; Caring experiences, EOL treatment options, and the score of the Hospice Care Attitude Scale\u003c/p\u003e \u003cp\u003e\u0026bull; Respondents who had cared for relatives or friends with terminal illnesses were more willing to make AD than those who had not (OR\u0026thinsp;=\u0026thinsp;1.68, 95% CI [1.14, 2.49]).\u003c/p\u003e \u003cp\u003e\u0026bull; Respondents who chose suffering-alleviating treatments, despite knowing that their limited lives might not be extended, were more likely to set up AD than those who chose life-prolonging treatments (OR\u0026thinsp;=\u0026thinsp;2.20, 95% CI [1.53, 3.17]).\u003c/p\u003e \u003cp\u003e\u0026bull; Those who scored higher in the Hospice Care Attitude Scale were more willing to make AD (OR\u0026thinsp;=\u0026thinsp;1.06, 95% CI [1.02, 1.10]).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;619 (85,5%) expressed that it was necessary to discuss the treatment and care at the end of their lives with HCPs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLim et al., 2022\u003c/p\u003e \u003cp\u003eMalaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;12 (3.1%) had heard of ACP\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;20 (5.2%) were familiar with ACP concepts\u003c/p\u003e \u003cp\u003e\u003cb\u003eHad not heard of\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;361 (93.8%) SDM\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;346 (89.9%) EOL decision making\u003c/p\u003e \u003cp\u003e- n-220 (57,1%) living will\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;290 (75.3%) durable power of attorney\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe most common sources of information for those familiar with ACP were\u003c/b\u003e\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;62 (161%) mass media\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;39 (10.2%) friends\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;32 (8.3%) reading materials\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;26 (6.8%) relatives\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;12 (3.1%) family doctors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter the term ACP was explained\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;331 (86%) ACP services should be provided in primary care clinics\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;330 (85.7%) felt that discussion on ACP was necessary\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;325 (84.4%) were willing to discuss ACP in the future\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;311 (80.8%) were in favour of ACP.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;75 (19.5%) had thought of writing a living will\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;23 (6%) had written a living will.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eChoice of SDM were\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;124 (38.2%) spouse\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;122 (37.5%) family members\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;77 (23.7%) preferred HCPs\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;2 (0.6%) close friends\u003c/p\u003e \u003cp\u003e\u003cb\u003ePreferences for AD\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;277 (84.2%) verbal directive to a family member or acquaintance\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;221 (67.2%) written documentation and to give a copy to their healthcare provider and family\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;74 (22.4%) audio or video tape recording of wishes\u003c/p\u003e \u003cp\u003e\u003cb\u003eWhen is right time to complete AD\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;278 (72.2%) if had dementia (n\u0026thinsp;=\u0026thinsp;308; 80.0%), cancer (n\u0026thinsp;=\u0026thinsp;305; 79.2%), heart attack and on a breathing machine (n\u0026thinsp;=\u0026thinsp;283; 73.5%), or in a coma (n\u0026thinsp;=\u0026thinsp;267; 69.4%)\u003c/p\u003e \u003cp\u003e- More than 80% agreed ACP topics should include CPR, use of artificial breathing machine, tube feeding, place of death, haemodialysis, place of care, and chemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNg et al., 2017\u003c/p\u003e \u003cp\u003eSingapore\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;58 (14.4%) had heard of ACP, mostly through the media (67.9%), from family and friends (21.4%) and healthcare providers (21.4%)\u003c/p\u003e \u003cp\u003e- Respondents who were previously aware of ACP were more likely to be older, Singaporean, and tended to make important personal decisions on their own as compared to those who have not heard about ACP\u003c/p\u003e \u003cp\u003e- There was no association between the respondents\u0026rsquo; knowledge scores and the channels through which they had learned about ACP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eTop 3 reasons for being unwilling to begin an ACP discussion after learning more about ACP were\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;55 (35%) still healthy\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;22 (14%) thinks ACP is unnecessary\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;14 (8.9%) would like family to make that decision\u003c/p\u003e \u003cp\u003e\u003cb\u003eCommon reasons to discuss ACP were\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;340 (83.7%) having a serious life-threatening illness\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;312 (76.8%) if the respondent knew more about ACP (76.8%)\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;303 (74.6%) if the respondent was an older age\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;236 (60.1%) were willing to begin an ACP discussion after being education about ACP\u003c/p\u003e \u003cp\u003e- Those who were willing to begin an ACP discussion were more likely to be receiving financial support from their family (40.7% vs 30.6%, P\u0026thinsp;=\u0026thinsp;0.042, χ\u0026sup2; = 4.1, df\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e \u003cp\u003e- There was also a trend towards those who tend to make important personal decisions together with their family (60.4% vs 48.4%, P\u0026thinsp;=\u0026thinsp;0.051, χ\u0026sup2; = 6.0, df\u0026thinsp;=\u0026thinsp;2) and those with university or higher education qualification (31.8% vs 21.0%, P\u0026thinsp;=\u0026thinsp;0.051, χ\u0026sup2; = 9.4, df\u0026thinsp;=\u0026thinsp;4) were also more likely to have greater willingness to begin an ACP discussion.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- 26.8% of those who had previously heard of ACP knew how to begin an ACP discussion, 12.5% of them had a prior ACP discussion.\u003c/p\u003e \u003cp\u003e- There were 7 (12.5%) of the 56 respondents who had a previous discussion regarding ACP.\u003c/p\u003e \u003cp\u003e- Respondents who were more likely to have had a previous ACP discussion were those who had answered \"\"yes\"\" to knowing how to begin an ACP discussion (71.4% vs 20.4%, P\u0026thinsp;=\u0026thinsp;0.012)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- The top 3 methods which respondents perceived as good methods for learning more about ACP were advertisements in the media (86.9%), general practitioners or other healthcare providers advocating ACP (70.4%) and brochures given out by the government (62.6%).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNi et al., 2021\u003c/p\u003e \u003cp\u003eChina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;700 (62.8%) had heard of life-sustaining treatments\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;203 (18.2%) had heard of AD n\u0026thinsp;=\u0026thinsp;203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;691 (62.0%) The main reason given to complete an AD was to ease burden on their families and to make decisions for themselves.\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;965 (86.6%) were willing/fairly willing, after learning about AD, to make their EOL treatment decision s(AD) if it was legal.\u003c/p\u003e \u003cp\u003e\u003cb\u003eThe main reasons for reluctant to make an AD were\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;528 (47.4%) It is too early to make one\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;371 (33.3%) The law is not perfect\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;371 (33.3%) It is no use to make one\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;330 (29.6%) Not familiar with it\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 \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePark et al., 2019\u003c/p\u003e \u003cp\u003eSouth Korea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOf the n\u0026thinsp;=\u0026thinsp;1005 individuals:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;162 (16.1) knew about AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;102 (10.2%) were aware of physician orders for life-sustaining treatments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eWillingness to conduct ACP when\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;x (46.5%) healthy\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;x (56.5%) diagnosed with serious disease\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;x (63.6%) the disease state was aggravated\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;x (68.3%) the status was terminal\u003c/p\u003e \u003cp\u003e\u003cb\u003eReasons for lacking the intention to prepare an AD\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;216 (30.5%) feel psychologically anxious or uncomfortable preparing for worsening health problems\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;147 (20.8%) would change their mind when faced with the situation in the future even if they make the decision now\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;96 (13.6%) not sure if things will be handled as per their wishes and reflected in AD\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;85 (12%) their family will make a wise decision when they are unable to do so\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;78 (11%) do \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003enot\u003c/span\u003e know much about AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eSuitable times for writing an AD were\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;542 (32.6%) before all procedures or interventions with a high mortality risk\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;430 (25.9%) when visiting wards and emergency rooms of patients with specific severe diseases\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;342 (20.6%) when the patient was aged\u0026thinsp;\u0026gt;\u0026thinsp;65\u0026ndash;70 years when recently admitted to the hospital\u003c/p\u003e \u003cp\u003e\u003cb\u003eStrategies for Facilitating ACP\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;359 (35.7%) public promotion efforts and education regarding ACP\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;191 (19%) online programs and n\u0026thinsp;=\u0026thinsp;191 (19%) setting up offices where an AD could be registered\u003c/p\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;142 (14.1%) Providing payment for ACP through national medical insurance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSellars et al., 2021\u003c/p\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;431 (38.5%) had heard of ACP\u003c/p\u003e \u003cp\u003e- 58% reporting they did not know if there were laws regarding SDM.\u003c/p\u003e \u003cp\u003e- 33% reporting awareness of SDM laws existing in Australia.\u003c/p\u003e \u003cp\u003e- The median knowledge scores for people who had ever discussed ACP (3.0 vs 2.0, U\u0026thinsp;=\u0026thinsp;1 45 222, z\u0026thinsp;=\u0026thinsp;6.910, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), documented their ACP preferences (3.0 vs 2.0, U\u0026thinsp;=\u0026thinsp;71 984, z\u0026thinsp;=\u0026thinsp;4.087, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), or acted in the SDM role (3.0 vs 2.0, U\u0026thinsp;=\u0026thinsp;56 353, z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.694, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), were significantly higher compared with those who had not.\u003c/p\u003e \u003cp\u003e- \u003cb\u003eSource of learning or hearing about ACP\u003c/b\u003e (n\u0026thinsp;=\u0026thinsp;431)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;262 (60.8%) family and friends\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;202 (46.9%) media\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;173 (40.1%) HCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- n\u0026thinsp;=\u0026thinsp;117(10%) had completed ACP documentation.\u003c/p\u003e \u003cp\u003e- Of those who had been involved in an ACP discussion with other people (n\u0026thinsp;=\u0026thinsp;267)\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;163 (61%) had told someone about their future treatment preferences.\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;50 (30%) had documented ACP preferences.\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;230 (86%) had discussed the ACP preferences of someone.\u003c/p\u003e \u003cp\u003e\u0026bull; n\u0026thinsp;=\u0026thinsp;142 (13%) had acted as an SDM.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Preferred source(s) of obtaining more information to support SDMs to make their decisions were (n\u0026thinsp;=\u0026thinsp;1049)\u003c/p\u003e \u003cp\u003e\u0026bull; HCPs (59%, n\u0026thinsp;=\u0026thinsp;621),\u003c/p\u003e \u003cp\u003e\u0026bull; discussion with a family member or friend (23%, n\u0026thinsp;=\u0026thinsp;236),\u003c/p\u003e \u003cp\u003e\u0026bull; traditional media (7%, n\u0026thinsp;=\u0026thinsp;69),\u003c/p\u003e \u003cp\u003e\u0026bull; new media (6%, n\u0026thinsp;=\u0026thinsp;61),\u003c/p\u003e \u003cp\u003e\u0026bull; an \u0026lsquo;other source\u0026rsquo; (3%, n\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003cp\u003e\u0026bull; an event (3%, n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhyte et al., 2022\u003c/p\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- 33.3% knew about ACP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e- There is a positive correlation between the age of the general public and the preferred age for the initial ACP discussion (. = 0.368, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e- Australian males seem to prefer a slightly later initial ACP discussion in life (M\u0026thinsp;=\u0026thinsp;59.4 years, SD\u0026thinsp;=\u0026thinsp;14.8) compared to Australian females (M\u0026thinsp;=\u0026thinsp;57.1 years, SD\u0026thinsp;=\u0026thinsp;14.3; p\u0026thinsp;=\u0026thinsp;0.0047)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e- 14.1% have participated in ACP\u003c/p\u003e \u003cp\u003e- 21.1% have been involved with ACP of their friends or relatives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- The ideal age of initial ACP discussion is 58.1 years (SD\u0026thinsp;=\u0026thinsp;14.56)\u003c/p\u003e \u003cp\u003e- The mean share of doctor's ACP input is 39 (SD\u0026thinsp;=\u0026thinsp;31.3).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eACP - Advance Care Planning, AD - Advance Directive, DNACPR - Do Not Attempt Cardiopulmonary Resuscitation, EPA - Enduring Power of Attorney, HCPs \u0026ndash; Healthcare Professionals, SDM - Substitute Decision Making, EOL \u0026ndash; End-of-life. \u003cem\u003eStatistical notes\u003c/em\u003e: B - Regression coefficient, M \u0026ndash; Mean, OR - Odds Ratio, SD - Standard Deviation, SE - Standard Error\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\u003ePlace Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of outcome categories (themes), and sub-themes from included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome category (theme)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAwareness of ACP/AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of awareness assessed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness and knowledge of ACP/AD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactors influencing awareness of ACP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitudes towards engaging with ACP/AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactors influencing attitudes towards engaging with ACP/AD\u003c/p\u003e \u003cp\u003e- Legal issues\u003c/p\u003e \u003cp\u003e- Age\u003c/p\u003e \u003cp\u003e- Health status\u003c/p\u003e \u003cp\u003e- Knowledge and education\u003c/p\u003e \u003cp\u003e- Timing\u003c/p\u003e \u003cp\u003e- Family matters\u003c/p\u003e \u003cp\u003e- Additional factors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExperiences of ACP/AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiences of ACP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiences of AD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePreferences and expectations of ACP/AD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreferences of ACP/AD\u003c/p\u003e \u003cp\u003e- Promotion of ACP\u003c/p\u003e \u003cp\u003e- AD documentation\u003c/p\u003e \u003cp\u003e- Timing to engage in ACP/AD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExpectations of ACP/AD\u003c/p\u003e \u003cp\u003e- Items on AD forms\u003c/p\u003e \u003cp\u003e- Healthcare Professionals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eACP: Advance Care Planning; AD: Advance Directive\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eAwareness of Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eEight of the 11 studies assessed the general public\u0026rsquo;s awareness of ACP/AD. The terms used in these studies were interchangeable, referring to awareness and knowledge to evaluate the same phenomenon.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eType of awareness assessed\u003c/h2\u003e \u003cp\u003eParticipants were asked subjective questions of awareness/knowledge of ACP/AD in eight studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] and two studies [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] assessed awareness/knowledge of ACP including knowledge of SDM both subjectively and objectively using true-false statements.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eAwareness and knowledge of Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eThe general public\u0026rsquo;s awareness of ACP in the Asia-Pacific region was found across three studies, ranging from around 3% [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] to 39% [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] of study participants. The findings demonstrate that around one in three people knew about ACP [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and that it was common for participants to not know about other aspects of ACP such as the role of the SDM [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and were not aware of the terms \u0026lsquo;EOL decision making,\u0026rsquo; \u0026lsquo;living will\u0026rsquo; or \u0026lsquo;durable [sic] power of attorney\u0026rsquo; [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. However, more than half (55%) of the participants in the Sellars et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] study knew about ways to plan for future medical care when they could not make decisions for themselves.\u003c/p\u003e \u003cp\u003eSimilarly, awareness of AD was low across participants ranging from 14% [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] to 43% [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] across studies. Terminologies related to AD were also reported by few, for example, less than 10% of participants in Hong Kong had heard of \u0026lsquo;enduring power of attorney\u0026rsquo; (EPA) [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], and less than half (n\u0026thinsp;=\u0026thinsp;165, 43%) of community-dwelling adults in Malaysia had heard of a \u0026lsquo;living will\u0026rsquo; [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. The most common sources of ACP/AD information reported were the media, family and friends, HCPs, as well as other sources including legal practitioners and financial planners [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing awareness of Advance Care Planning\u003c/h2\u003e \u003cp\u003eOnly two studies reported on factors that influence awareness of ACP. The primary factors reported were being of an older age and making important personal decisions autonomously when compared to those who had not heard about ACP [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. One of the Australian studies [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] found that the median knowledge scores for people who had ever discussed ACP (3.0 vs 2.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), documented their ACP preferences (3.0 vs 2.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), or acted in the SDM role (3.0 vs 2.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), were significantly higher compared with those who had not.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eAttitudes towards engaging with Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eNine of the 11 included studies assessed the general public\u0026rsquo;s attitudes toward ACP/AD. Findings include being supportive of ACP, though few (20%) had thought of writing a living will [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], that the ACP/AD is useful and necessary [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and that having an AD was viewed as a basic human right [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] with many being happy to discuss ACP in the future [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Many agreed that an AD was a good approach to determine health care decisions prior to becoming mentally incompetent [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Furthermore, good communication skills and practices of clinicians when talking to patients and their families directly about ACP/AD, was considered favourable [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eFactors influencing attitudes towards engaging with Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eIn the context of the Asia-Pacific region, factors that influence the general public\u0026rsquo;s attitudes toward ACP/AD and engaging in relevant discussions and processes were found to be across legal issues, age, health status, knowledge and education, timing of such discussions, family matters, and more.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLegal issues\u003c/strong\u003e \u003cp\u003eThe legal status of ADs was found to impact participants\u0026rsquo; attitudes toward completing an AD [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] with participants noting that they would complete an AD if it was legislated [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Non-specific problems with the law were also noted as deterrents to completing an AD [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAge\u003c/strong\u003e \u003cp\u003eAge was found to be associated with willingness to engage in ACP/AD. Participants\u0026rsquo; age and their preferred age to initiate ACP discussions were positively correlated (ρ\u0026thinsp;=\u0026thinsp;0.368, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 respectively) [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Feeling too young to complete an AD was reported across studies [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. In contrast, the Keam et al. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] study found that younger age (20\u0026ndash;49) was associated with a sense of necessity for an AD compared with those aged\u0026thinsp;\u0026ge;\u0026thinsp;50 years (p\u0026thinsp;=\u0026thinsp;0.006). This may be due to older participants being potentially closer to the end of their lives than those younger, and hence do not wish to be reminded of their mortality.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealth status\u003c/strong\u003e \u003cp\u003ePoor health status, or having a serious life-threatening illness, was a factor associated with the willingness to engage in ACP/AD. This included the possibility of having a life-limiting illness, such as cancer or dementia, undergoing a life-sustaining treatment [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] or poor self-ratings of health [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Congruent to this, feeling healthy was the most common reason given by those unwilling to begin an ACP discussion [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eKnowledge and education\u003c/strong\u003e \u003cp\u003ePrior awareness or knowledge of ACP/AD was found to be associated with engagement, consequently, lack of such knowledge appeared to hinder engagement. Two studies found that education of ACP/AD, and having a higher education, was related to willingness to complete an AD [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Furthermore, prior knowledge of life-sustaining treatments was found to significantly increase the chance of making an AD by 1.87 times [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Conversely, reasons given by those who were unwilling to begin an ACP discussion include lack of knowledge about ACP generally [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and of the specific content and procedures related to an AD [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Participants who lacked intention to prepare an AD also reported a lack of knowledge of ACP/AD [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Not knowing how to begin an ACP discussion was also highlighted as impeding engagement [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTiming\u003c/strong\u003e \u003cp\u003eAnother factor that can impact participants\u0026rsquo; willingness to begin ACP discussions and AD development was feeling it was too early to do so [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. however, it could not be determined if this finding related to being too young or being too early in an illness trajectory. Consequently, Leong et al. [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] found that being \u0026lsquo;too young\u0026rsquo; hindered ACP/AD engagement. Gender, too, was a factor relating to the timing of ACP/AD engagement, as Australian males preferred a slightly later initial ACP discussion in life than Australian females [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFamily matters\u003c/strong\u003e \u003cp\u003eFamily was found to significantly influence attitudes toward engaging in ACP/AD. This impact includes both wanting to ease the burden on their family to make such decisions [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e] and preferring family members to make EOL decisions [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAdditional factors\u003c/strong\u003e \u003cp\u003eFindings highlight various other factors that can influence the general public\u0026rsquo;s attitudes towards engaging with ACP/AD. Positive factors include self-perceived level of optimism [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], and a positive attitude towards withdrawal of futile life-sustaining treatments, active pain control, and of hospice and palliative care [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Participants who had past experience caring for relatives or friends with terminal illnesses were significantly more willing to complete an AD compared to those who had not (OR\u0026thinsp;=\u0026thinsp;1.68, 95% CI [1.14, 2.49]) [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Those who would choose comfort care over active treatment, despite knowing that their time was limited and may not be extended, were more likely to complete an AD than those who chose life-prolonging treatments [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Factors that can hinder engagement with ACP/AD were also mentioned across the literature, such as believing they might change their minds [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e], and/or feeling uncomfortable discussing ACP topics [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eExperiences of Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eAround half of the included studies (n\u0026thinsp;=\u0026thinsp;5) assessed the general public\u0026rsquo;s experiences of ACP/AD. Those who had reported experience of previous ACP discussions varied from 13% [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] to 24% of study participants [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and the completion rate of AD ranged from 0.5% [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] to 10% [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Having acted in a SDM role was reported by few [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAdvance Care Planning\u003c/strong\u003e \u003cp\u003eWhile the Singaporean study conducted by Ng et al. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] reported only 13% of their sample reported having ACP discussions, the Australian studies, which had participants of a similar mean age, found that 14% and 24% of participants [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] respectively had done so. Of those who had been involved in an ACP discussion with others, in the Sellars and colleagues\u0026rsquo; study [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], most (79%) had discussed ACP with family, had told someone about their future treatment preferences (61%), and of these around a third (30%) had documented their preferences. A larger proportion (86%) of the group who had discussed ACP reported having discussed the ACP preferences of someone else as opposed to discussing their own ACP preferences [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] which may be due to not wishing to face one\u0026rsquo;s own mortality.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAdvance Directive\u003c/strong\u003e \u003cp\u003eCollectively, few participants reported experience with AD. The majority of those who had heard about AD in the Chan et al. study [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] had intended to complete an AD, though very few did (0.5%). Similarly, only 20% of the Malaysian cohort [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] had thought of writing an AD, with just 6% having done so. The Sellars et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] Australian study, too, found that only 10% of participants reported having completed ACP documentation (to document their future treatment preferences, to appoint an SDM, or both). In relation to AD, only the Sellars et al. [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] study reported experience of SDM with few of their sample (13%) indicating that they had enacted an SDM role and having made medical decisions on an adult\u0026rsquo;s behalf.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003ePreferences and expectations of Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eMost of the included studies (n\u0026thinsp;=\u0026thinsp;10) assessed the general public\u0026rsquo;s preferences and expectations for ACP/AD. The preferences expressed relate to: a) how best to promote and be educated about ACP, b) how to document preferences, including who should receive copies of AD, and c) the most optimal time for ACP/AD engagement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003ePreferences of Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003ePromotion of Advance Care Planning\u003c/strong\u003e \u003cp\u003ePublic promotion efforts and education, various media sources, and HCPs advocating for ACP were the most commonly reported means for promoting ACP. Online programs, setting up AD registration offices, and providing payment for ACP through a national medical insurance scheme were deemed important in the Korean study [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Advertisements in the media [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], including traditional and new media sources [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], receiving information from general practitioners or other HCPs advocating for ACP was noted in the Singaporean study and Australian studies, respectively [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Brochures on ACP, distributed by the government, was also deemed to be a preferred method of receiving information in a Korean study [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAdvance Directive documentation\u003c/strong\u003e \u003cp\u003eDocumentation of AD can be verbal, visual (video), audio (recorded), and/or written. In one study (from Malaysia), 84% preferred a verbal directive to a family member or acquaintance rather than documenting preferences, while some (67%) were open to written documentation [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Audio or videotape recordings of wishes was preferred by less than a quarter of this sample [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Participants noted they were open to giving copies of their AD to their healthcare provider and family [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTiming to engage in ACP/AD\u003c/strong\u003e \u003cp\u003eThere are a variety of factors that need to be considered when considering the optimal timing of ACP discussions and AD completion. Those found across studies include before becoming mentally incompetent [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], when still healthy [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], when diagnosed with a life-limiting illness, such as cancer [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], when an illness progresses or reaches terminal stage [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], and prior to receiving treatments with a high mortality risk [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. An Australian study found that 58 years was the ideal age to initiate ACP discussions [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. Older age (\u0026ge;\u0026thinsp;65 years) and a variety of hospitalisation combinations, e.g., when patient has a severe illness and is hospitalised, were also found in one of the Korean studies to be the preferred time to engage in AD [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eExpectations of Advance Care Planning/Advance Directive\u003c/h2\u003e \u003cp\u003eExpectations of ACP/AD included what items the general public expect to find within AD forms and their expectations of HCPs in relation to initiating such discussions, and the communication skills HCPs should possess to undertake such activities, and the realities of these expectations.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eItems on Advance Directive forms\u003c/strong\u003e \u003cp\u003eLife-sustaining treatment options, such as CPR and mechanical ventilation [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] and chemotherapy, as well as place of care and death [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e] were items that would be expected to be found on AD forms. Most participants (91%) in the Keam et al. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e] study suggested that hospice and palliative care information should be included in AD forms. These participants also noted that clarification of treatment options is needed in such documentation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHealthcare Professionals\u003c/strong\u003e \u003cp\u003eStudies reported that the general public expect HCPs to engage in ACP conversations [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], to have good communication skills to discuss AD with patients [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], to talk directly to a patient about their situation [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], to adhere to legislation when progressing with AD documentation [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], and provide more information to help support SDMs to make decisions [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. However, the Japanese cohort felt it too confronting to discuss AD, rather they expect a doctor to give them hope [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. These differences in findings likely demonstrates the diversity of cultural norms across the Asia-Pacific region. Furthermore, the Australian general public [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] expected around double the input into the ACP content from clinicians than that reported by the clinicians (doctors and nurses) surveyed which suggests that their expectations do not necessarily reflect current clinical practices.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe perceptions of the general public towards ACP/AD in the Asia-Pacific region has not been systematically analysed. To the best of our knowledge, this is the first review to collate existing evidence of the awareness of, attitudes towards, experiences with, and expectations of ACP/AD of the general public in the Asia-Pacific region. Eleven studies met the search criteria, with most being published between 2017 and 2022. The limited number of included studies conducted in the first half of this decade may be related to the concepts of ACP/AD being in their infancy in some countries in the Asia-Pacific region [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This review found that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low. While they believe ACP is necessary and important, only a minority have had previous discussions regarding ACP and the low prevalence of completion of AD. Various factors were found to influence willingness to engage in ACP/AD, such as legal issues and prior awareness/knowledge. Medical professionals were expected to not only initiate ACP discussions but also to have good communication skills. Legal parameters to support ADs were also considered to be paramount.\u003c/p\u003e \u003cp\u003eThe collective findings of this review suggest that the general public of the Asia-Pacific region have limited awareness of ACP/AD. The Australian general public demonstrated a higher awareness of ACP compared to the other countries of the Asia-Pacific region represented in this review [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e], which is likely due to the more advanced policy and health system acceptance of these concepts in Australia [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. ACP/AD is a relatively new concept in the Asia-Pacific region, and there are variations in legislation regarding ACP/AD across different countries [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]. This finding aligns with a previous scoping review on the global perspective of public perception of ACP, which found that inadequate public understanding of ACP was due to widespread beliefs of misinformation, or limited access to correct information [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Our findings are relatively consistent with a systematic review on the opinions of older individuals on ACP [[\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e] that found advanced age and having a higher education degree are positively associated with ACP knowledge and awareness [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our review highlighted that the sources of ACP information were primarily via the media, family and friends, and HCPs. As the general public\u0026rsquo;s lack of awareness of ACP negatively impacts their participation in ACP [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], it is important to promote ACP/AD and educate the general public about ACP using the media sources with which they are mostly likely to engage.\u003c/p\u003e \u003cp\u003eThe majority of the general public in the Asia-Pacific region countries under study agree that ACP/AD is useful and necessary [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. This is consistent with previous systematic reviews which found those who had a positive perception of ACP agreed that ACP was necessary [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Willingness to engage in ACP/AD were found to depend on many factors, such as age, health status, legal issues, knowledge and education, and timing. Legal considerations too, such as the AD being underpinned by legal requirements, which increase the general public\u0026rsquo;s confidence in the process and the ultimate outcomes, were found to play a significant role in the decision to engage with ACP/AD [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. This finding is consistent with those of previous systematic reviews of ACP [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] that found diversity in legal and policy approaches to ACP across countries. The absence of a clear legal framework creates uncertainty about the legal standing of ACP and obstructs its implementation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. Therefore, it is necessary to establish a systematic structure that encompasses laws and policy structures to positively impact social awareness and promote ACP [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite varying rates of previous discussions regarding ACP reported across countries [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and evidence of positive perceptions of ACP/AD [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], there was little completion of AD [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Previous studies have pointed out that low AD completion rates were often linked to a lack of knowledge about AD [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. This phenomenon may be explained by the inadequate promotion of AD among the public and a lack of appetite to discuss such matters [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]. Differing cultural factors and belief systems may also impact on AD completions. Importantly, cultural values and belief systems also play a central role in shaping ACP engagement in the Asia-Pacific region. In many Asian cultures, family-based decision-making is normative, and EOL decisions are often viewed as a collective family responsibility rather than an individual act [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Taboos surrounding discussions of death and religious beliefs may further reduce willingness to engage in ACP or complete Ads [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. These cultural and religious dynamics provide important contextual explanations for the low rates of ACP action observed across studies.\u003c/p\u003e \u003cp\u003eSeveral studies reported that the general public expect HCPs to be their preferred source of information [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] and should possess good communication skills when discussing treatment options and EOLC (via ACP) or when completing an AD [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. HCPs therefore need to have the necessary communication skills to discuss AD with patients and to provide them with sufficient information to support their decision-making process [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. This result is consistent with those of a prior systematic review [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and scoping review [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], within the global context, that the general public expect HCPs, particularly physicians, to initiate AD discussions. A previous integrative review found that there is a lack of education, training to upskill health professionals, as well as a lack of guidance for initiating and supporting them with ACP activities [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Therefore, public promotion efforts and education should include specific education for HCPs to ensure they are well-versed in ACP/AD topics and are skilled at initiating such discussions and to prepare AD.\u003c/p\u003e \u003cp\u003eThe challenge facing HCPs who advocate for ACP/AD is the population\u0026rsquo;s low awareness of ACP/AD and even lower numbers of persons engaging with and actioning these [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. Even when the general public are aware of ACP/AD and believe it to be important and necessary [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], few were found to follow-up this sentiment with documenting an AD [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. These challenges suggest that public campaigns are needed to raise public awareness through education about what ACP entails and how to document an AD. However, education alone will not be sustained without the support of the larger health and governmental systems by developing and implementing legal frameworks and public policies to address the legal and ethical barriers that may hinder the effective implementation of ACP/AD. Expectations of medical professionals to engage in ACP discussions, provide information to make decisions, and have good communication skills when discussing ACP were highlighted in the findings [\u003cspan additionalcitationids=\"CR46 CR47\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. ACP/AD-specific education for HCPs is critical to improve their knowledge and understanding of these concepts, and to improve their communication skills in relation to such discussions. Given the significant influence of cultural and religious norms, ACP strategies in Asia\u0026ndash;Pacific settings must also be culturally responsive, family-inclusive, and sensitive to variations in belief systems. These strategies combined are essential to create a supportive environment in which the general public will feel supported to not only discuss their future health care needs, in the event they lose their decision-making capacity, but to also complete an AD.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAs with all reviews, this literature review has limitations. Firstly, due to the sensitive nature of the topic, self-selection bias of participants in the included studies is a possibility, as study participants may have had a particular interest in/experience of ACP to consent to participate. Secondly, as there are no standardised methods or tools to collect data about ACP discussions or AD completions, and most included studies did not report the reliability or validation of the instruments, the credibility of our findings is limited. Thirdly, due to the countries represented in this review our findings may not be fully generalisable to other countries in the Asia-Pacific region and elsewhere. Fourthly, while care was taken to find all relevant studies across multiple databases, it is possible that some relevant studies were not found. Our search was also limited to studies only available in English. Fifthly, our use of a narrative approach to data synthesis involved an interpretive, and hence subjective, process that may have impacted the accuracy and transparency of our findings. Even so, data were extracted by two authors independently and the review team discussed the categorised and collated findings on a number of occasions to identify and refine themes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis review highlights that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low. Although people across this region recognise the usefulness and necessity of ACP/AD, only a small percentage had actioned these. There are various factors influencing people's willingness to engage in ACP/AD, such as legal issues and prior awareness/knowledge which need to be researched further and addressed, particularly across the various cultural contexts. Findings revealed that the general public expect medical professionals to have good communication skills when discussing ACP as that they would like ADs to be supported by legal parameters to protect patient autonomy and to facilitate their contribution to their EOL treatment. HCPs initiating ACP discussions, together with both legal and policy support for ACP/AD, were identified as the most important means for facilitating higher levels of awareness and activation of ACP/AD processes. Therefore, it is important to first get ACP/AD on policy agendas and to raise the general public\u0026rsquo;s awareness of ACP via promotion campaigns and by providing freely available ACP education to debunk negative perceptions of ACP/AD. Such initiatives would benefit patients (by having their wishes documented and respected, such as dying at their preferred place), family members (due to reduced burden when decisions need to be made), HCPs (knowing the patient\u0026rsquo;s and their family\u0026rsquo;s EOL treatment decisions), and systems (through fewer inappropriate hospitalisations and more appropriate use of resources). Further research is needed to underpin multimodal strategic approaches and to inform the development of culturally appropriate education interventions to be implemented at a population level.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eACP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvance Care Planning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvance Directive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEOL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd\u0026ndash;of\u0026ndash;Life\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEOLC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnd\u0026ndash;of\u0026ndash;life Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEnduring Power of Attorney\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCPs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealthcare Professionals\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMMAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMixed Methods Appraisal Tool\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOdds Ration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSpecial Administrative Regions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSDM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSubstitute Decision Making\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCorresponding author\u003c/h2\u003e \u003cp\u003eCorrespondence to Piyawan Pokpalagon\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe author (s) received no specific funding for this work. PP has received scholarship support from Faculty of Medicine Ramathibodi Hospital, Mahidol University, to support her work as a Postdoctoral Research Fellow and for publication purposes.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eProject administration: PP; Conceptualisation of review protocol and search strategy: PP, SC, PY; Abstract/full text screening, data extraction and analysis: PP, SC, GS; Interpretation of findings: PP, SC, GS, PY; Manuscript writing and editing: PP, SC, GS, PY.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe lead author would like to express gratitude to the Faculty of Health, School of Nursing at Queensland University of Technology (QUT) for accepting her as a Visiting Postdoctoral Research Fellow and to Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University for scholarship support. Additionally, the lead author wishes to sincerely thank her supervisors, PY and SC, for their guidance, invaluable advice, and kind support. Special thanks are also extended to GS for all contributions, and to the QUT health liaison librarian for assisting in the search strategy.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used for this review were extracted from publicly available journals. The Excel file in which we stored the extracted data is available upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAgeing and health. 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Int J Environ Res Public Health 2023, 20(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartina D, Geerse OP, Lin CP, Kristanti MS, Bramer WM, Mori M, Korfage IJ, van der Heide A, Rietjens JA, van der Rijt CC. Asian patients' perspectives on advance care planning: A mixed-method systematic review and conceptual framework. Palliat Med. 2021;35(10):1776\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLovell A, Yates P. Advance Care Planning in palliative care: a systematic literature review of the contextual factors influencing its uptake 2008\u0026ndash;2012. Palliat Med. 2014;28(8):1026\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlackwood DH, Walker D, Mythen MG, Taylor RM, Vindrola-Padros C. Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. J Clin Nurs. 2019;28(23\u0026ndash;24):4276\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolmohammadi M, Ebadi A, Ashrafizadeh H, Rassouli M, Barasteh S. Factors related to advance directives completion among cancer patients: a systematic review. BMC Palliat Care. 2024;23(1):3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson RJ, Bloch S, Armstrong M, Stone PC, Low JT. Communication between healthcare professionals and relatives of patients approaching the end-of-life: A systematic review of qualitative evidence. Palliat Med. 2019;33(8):926\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemsley B, Meredith J, Bryant L, Wilson NJ, Higgins I, Georgiou A, Hill S, Balandin S, McCarthy S. An integrative review of stakeholder views on Advance Care Directives (ACD): Barriers and facilitators to initiation, documentation, storage, and implementation. Patient Educ Couns. 2019;102(6):1067\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai PSM, Mohd Mudri S, Chinna K, Othman S. The development and validation of the advance care planning questionnaire in Malaysia. BMC Med Ethics. 2016;17(1):61.\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, Awareness, Attitude, Experience, Expectation, Public opinion, Asia-Pacific, Systematic Review","lastPublishedDoi":"10.21203/rs.3.rs-5099874/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5099874/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePopulations are rapidly ageing. Advance Care Planning (ACP) is an important activity to help prepare for future healthcare needs. Little is known of the perceptions of the general public of the Asia-Pacific region in relation to these activities. Within the context of the Asia-Pacific region, this review aimed to explore awareness of, attitudes towards, experiences of, and the needs, wishes, and/or expectations related to ACP/Advance Directives (AD) of the general public.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe systematic review protocol was registered with PROSPERO (December 17, 2023): CRD42023491109. PubMed, CINAHL, PsycINFO, Embase, and Emcare databases were searched 2013 to 2023 for primary research, of any design, that reported perspectives and experiences of the general adult public of the Asia-Pacific region relating to their awareness, attitudes, experience, and expectations of ACP/AD. Selected studies were quality appraised using the Mixed Methods Appraisal Tool. Findings were synthesised using Cochrane's narrative synthesis approach.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOut of 3105 records retrieved, 11 studies were included in this review. This review found that awareness of ACP/AD among the general public in the Asia-Pacific region is relatively low and it was not uncommon for them to know nothing about substitute decision maker decision makers and other terms related to ACP/AD. While they believe ACP is necessary and important, only a minority have had previous discussions regarding ACP and the reported completion of AD was minimal. Various factors that influence people's willingness to engage in ACP/AD were found, such as wanting legal parameters to protect patient autonomy. Expectations of medical professionals to have good communication skills when discussing ACP were highlighted as well as the need for legal parameters to support ADs.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis review highlights that awareness of ACP/AD among the general public in the Asia-Pacific region is low. As proven by the small number of papers which informed this review, more robust studies are needed on various aspects of this topic in the context of the Asia-Pacific region. Such studies would inform the best ways to move forward in improving the awareness and knowledge of, and to improve attitudes towards, ACP/AD to ensure people\u0026rsquo;s treatment decisions are discussed, documented, respected and enacted.\u003c/p\u003e","manuscriptTitle":"The general public’s perceptions of advance care planning (ACP) in the Asia-Pacific region: a systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 08:10:39","doi":"10.21203/rs.3.rs-5099874/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-06T02:59:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-01T12:25:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-09-30T01:16:35+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":"0d5c5958-aaaa-4482-86ca-94ef01aa3676","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:05:18+00:00","versionOfRecord":{"articleIdentity":"rs-5099874","link":"https://doi.org/10.1186/s12904-026-02109-w","journal":{"identity":"bmc-palliative-care","isVorOnly":false,"title":"BMC Palliative Care"},"publishedOn":"2026-04-23 15:59:15","publishedOnDateReadable":"April 23rd, 2026"},"versionCreatedAt":"2026-01-20 08:10:39","video":"","vorDoi":"10.1186/s12904-026-02109-w","vorDoiUrl":"https://doi.org/10.1186/s12904-026-02109-w","workflowStages":[]},"version":"v1","identity":"rs-5099874","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5099874","identity":"rs-5099874","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}