Advance directives (AD) are widely recognized as expressions of intent for end-of-life (EOL) care. However, cases have been reported in which the wishes of terminally ill elderly patients regarding their medical care cannot be fulfilled, despite completion of an AD, prompting discussions about the limitations of ADs  . Therefore, in the context of EOL care for the elderly, interest in advance care planning (ACP) has increased as an approach that respects the wishes of the individual, letting that person live in the manner of his or her choosing until the end. ACP has been defined as “a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care”  . As such, the ACP process is regarded as entailing repeated discussions among the target individual, his or her family, and medical and long-term care providers.
Systematic reviews of ACP have demonstrated its effectiveness   . Commencing ACP at an early stage is considered to increase the likelihood that the patient’s wishes will be respected and that he or she will experience less pain at the EOL stage  . Moreover, it has also become clear that ACP reduces invasive procedures and treatments, and is associated with improved quality of life (QOL) and reduced medical expenses    . In randomized controlled trials studying ACP, groups receiving ACP intervention showed increased patient and family satisfaction at the EOL stage, and reduced anxiety and depression for the bereaved family  .
The current authors believe nurses are uniquely positioned to guide patients in ACP discussions. Nurses spend a lot of time with their patients. They provide support during the preparation, anticipation, procedures themselves, and consequences―both positive and disappointing―of those procedures  . Therefore, it is considered important for nurses to take the initiative to practice ACP.
However, many patients do not practice ACP despite facing a serious illness  . Factors that have been cited as hindering the practice of ACP on the part of patients include a lack of interest in ACP and a lack of preparation for making medical care decisions at the EOL stage   . In addition, factors that have been pointed to on the part of medical professionals include challenges such as not being able to provide useful information that will serve as a guide for making decisions about ACP and time constraints   . Given this situation, in order to address the factors hindering ACP practice and encourage its implementation, it is necessary to improve the readiness for ACP on the part of the elderly, their families, and medical professionals, all of whom participate in the ACP process.
The aim of this study was to clarify content that has been described as “readiness for ACP on the part of the elderly”. In order to address the factors hindering ACP practice and encourage its implementation, it is necessary to improve the readiness for ACP on the part of the elderly, their families, and medical professionals, all of whom participate in the ACP process. Through this literature review, we intend to gain the insight required for proposing future improvements of the situation surrounding ACP.
2.1. Literature Extraction Method
Using the CINAHL and PubMed databases, we conducted a search using “advance care planning” and “readiness” as keywords with “65 years or older” as a condition. No limitation was set for the year of publication. As a result of the search, we identified a total of 60 articles consisting of 25 articles from CINAHL and 35 from PubMed.
Of the 42 unique articles that remained after we eliminated duplicates, we reviewed the titles and abstracts of 30 articles, because the full text of the remaining 12 was not available. Of these 30 articles, we conducted a careful reading of the full text of 23 articles, after eliminating 6 that did not deal with elderly people and 1 that was no description about ACP. Of these 23 articles, we excluded 11 articles that have no description about the readiness for ACP. Thus, 12 articles were selected as targets for the final analysis  -  (see Figure 1).
2.2. Analysis Method
We conducted a careful reading of the 12 articles and extracted passages relating to ACP readiness from their results and discussion sections in line with the objective of our study.
The geographical locations (countries) where these 12 studies took place were the United States, Canada, Hong Kong, and other countries. The type of the study was the most in qualitative study with 8, followed by 3 in quantitative research and 1 in mixed methods study.
ACP readiness was broadly divided into preparations on the part of the elderly themselves, family members, and medical professionals.
Figure 1. Selection process flowchart.
3.1. Preparations by the Elderly Themselves
As readiness of the elderly themselves, four contents were extracted from 8 articles.
1) “Mental preparedness to listen to explanations given by medical professionals”
It was shown that elderly people make mental preparations for listening to explanations from medical professionals about the anticipated course and content of treatment  .
2) “Preparations for asking questions of medical professionals”
In order to make decisions concerning future medical and long-term care, elderly people were reported to organize the necessary information in preparation for asking questions of medical professionals about points that are unclear or about which they have doubts  .
3) “Understanding the advantages and disadvantages of treatment”
It was found that elderly people possess knowledge and understanding of the advantages and disadvantages of the treatments they will undergo  .
4) “Communication of one’s own preferences and wishes”
Several studies made clear that elderly people convey their preferences and wishes to their families, loved ones, and medical professionals. Specifically, it was shown that they inform family members and medical professionals about the assignment of proxy decision-makers and matters concerning the balance of life-prolonging treatments, QOL, and life expectancy  -  .
3.2. Preparations by Family Members
As readiness of family members, two contents were extracted from 2 articles.
1) “Acceptance of explanations relating to prognosis”
Family members were shown to require mental preparedness for listening to and accepting the explanations from medical professionals about the state of a disease and its prognosis  .
2) “Understanding the preferences and goals of the elderly themselves”
As family members prepare before commencing ACP, it has been shown that a need for communication exists in order for the preferences and intentions of the patient to be understood and that this communication will lead to trust in the event that a family member becomes a proxy decision-maker  .
3.3. Preparations by Medical Professionals
As readiness of medical professionals, two contents were extracted from 2 articles.
1) “Education for conducting discussions with family members and with the elderly themselves”
Physicians have realized that they lack the requisite skills for providing information to patients and their families and for holding discussions that would allow them to practice ACP and have recognized the necessity of receiving education on how to do so  .
2) “Judgements of the timing of beginning ACP”
It was shown that medical professionals need to begin providing information that will assist decision-making once they have properly assessed that the patient and family members have made preparations to discuss ACP and are ready to commence ACP  .
Based on our results, the most frequently reported factor in readiness for ACP was elderly people informing their families and physicians of their intentions. This may attest to the importance of elderly people making their preferences and wishes about care and treatments during their EOL stage known to others. The practice of ACP by the elderly has been reported to be profoundly associated with individuals’ values, beliefs, and experiences  . For the elderly to express their intentions as “readiness for ACP”, in addition to understanding their own circumstances, it also appears to be necessary that they confront their own values and beliefs. A matter that was demonstrated as readiness for ACP on the part of the elderly, their family members, and medical professionals was preparation for mutual communication. Commencing ACP seems to require mental preparation on the part of the elderly and their family members for accepting explanations from and beginning mutual discussions with medical professionals about a medical condition and its prognosis. Furthermore, from the results of this study, the willingness of the elderly and their families to question medical professionals was also shown to indicate readiness for ACP. From this, it was considered important for the elderly and their family members to also be able to interpret and deepen their understanding of the information provided, rather than simply accepting unilateral explanations from medical professionals. In addition, with regard to readiness on the part of medical professionals, it is important to begin approaches that involve the careful assessment of the individual characteristics of the elderly to identify and determine timing and methods suited to the individual. In this way, it is important for all three parties to establish a cyclical relationship to prepare for mutual discussion about ACP. To that end, it seems necessary to understand the basic concept of ACP, which is a process of conscious communication between all parties.
The usefulness of ACP, which involves proactive mutual discussion about how elderly people want to live and enter their final stage of life, has already been made clear in previous studies  . At the same time, however, we found that many challenges were described that constituted barriers to ACP. One of them, discussion between elderly people and their families about death and bereavement, has been recognized as a social taboo and is more often than not perceived in negative terms  . In order to solve the problem, medical professionals are required to have the ability to discuss with the elderly and their families repeatedly and to facilitate ACP. Therefore, it is necessary to master the ability to play the role of facilitator. In this study, the original readiness for ACP of nurses was not clarified. It seems necessary to clarify the readiness of the nurse taking initiative in ACP in the future.
The limitations of this study include that the literature search was done with only two databases, CINAHL and PubMed, that some of the literature proved difficult to obtain, and that there were few articles explicitly relating to ACP readiness. In the future, we plan to expand the scope of the target literature and develop our analysis method in order to conceptualize ACP readiness.
Based on the results of this study, expression by the elderly of their own intentions and the establishment of communicative relationships among all three parties involved in the discussion process―elderly persons, their family members, and medical professionals―were shown as readiness for commencing ACP. It was suggested that enhancing these types of readiness would help reduce the barriers to ACP, thereby facilitating its practice.
This study was supported by JSPS KAKENHI Grant Numbers 16K20716.