Enhancing readiness for advance care planning among community-dwelling older adults with frailty: A mixed-method systematic review

Abstract

Background

Given uncertain illness trajectories faced by older adults with frailty and risk of decline and poor outcomes, intervention development for readiness to engage with advance care planning may confer benefits. However, evidence in this area remains limited.

Aim

• 1.
  To identify, appraise and synthesise evidence on the components, contexts, processes, and linkages with the causal pathways and outcomes of readiness for advance care planning among community-dwelling older adults with frailty.
• 2.
  To construct a logic model to inform intervention development.

Design

A mixed-methods systematic narrative review, underpinned by the COM-B system behaviour change model and employing thematic data synthesis.

Data sources

Primary studies were included using experimental or observational designs, qualitative and quantitative. Eligible studies were identified through searches of four electronic databases from inception to January 19, 2025.

Results

26 articles met the inclusion criteria. The data synthesis generated 14 themes across the three COM-B system components. The review identified the components of older adults' readiness, such as their limited physical and cognitive capacity for engaging in ACP (capability), influence and involvement of family (opportunity), and their desire to maintain the present and fear of change (motivation). It emphasised that readiness for advance care planning is a dynamic process influenced by family carers' and professionals' attitudes and behaviours, uncertainties inherent in older adults' conditions, as well as healthcare system, political, and social factors. The review also highlighted the uncertainties and ongoing changes involved in readiness, such as fluctuating physical and cognitive capabilities and changeable social situations. Based on these findings, a logic model was constructed to guide intervention development, outlining the components, intended outcomes, and influential factors.

Conclusion

Individual behaviour change models alone are insufficient to demonstrate older adults' readiness for advance care planning, as various external factors can influence their readiness. This emphasised the need for a comprehensive understanding of the contextual factors affecting readiness and the importance of flexibility in adapting interventions accordingly. Continuous assessment and enhancement of an individual's readiness for advance care planning, initiating conversations about what matters to them now, and improving family carers' readiness for advance care planning by assessing family dynamics and relationships are essential in practice. Further research is needed to elucidate the processes and causal pathways between intervention components and intended outcomes. This systematic review was registered on PROSPERO (CRD42023389337).