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Background: Advance care planning can be challenging because discussing end-of-life care often has negative connotations. Gamification is a novel approach to encourage advance care planning conversations in Western culture., Aim: To co-design a game with multiple stakeholders to promote advance care planning in Chinese communities., Design: A two-phase design guided by the Medical Research Council framework for developing complex interventions was adopted between May 2019 and August 2020. In phase I, a game prototype was developed based on literature review, expert consultation and end-user consultation. In Phase II, the game prototype was tested among end-users and refined according to their feedback and expertise of a multi-disciplinary team through an iterative process., Setting/participants: Experts in the field of aged care, palliative care, life education and game development and Chinese community-dwelling adults aged 60 years or older., Results: A board game called ' The Five Tastes Found in a Grocery Store ' was developed. The game design was shaped by Bandura's Self-efficacy theory and feedback from experts and end-users. The participants generally found the gaming experience enjoyable and appreciated the opportunity to discuss end-of-life care openly., Conclusions: This study is the first to develop an evidence-informed, theory-based, culturally sensitive game for promoting advance care planning in the Chinese community using a co-design approach., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To examine the acceptability of a board game newly developed through a co-design process for promoting end-of-life care discussion among Chinese older adults., Methods: A multi-centre mixed method study, including a one group pre-test post-test study and focus group interviews, was conducted. Thirty older adults participated in a one-hour game session in a small group format. Acceptability was assessed by attrition rate and satisfaction with the game. Participants' experiences with the game were explored qualitatively. Within-subject changes in self-efficacy and readiness for advance care planning (ACP) behaviours were also examined., Results: The players generally had positive experiences with the game, giving a low attrition rate. A significantly higher level of self-efficacy in sharing end-of-life care preferences with surrogates was reported after the game session (p = 0.008). There was a slight increase in the proportion of players indicated that they would complete ACP behaviours in the coming months immediately after the intervention., Conclusion: A serious game is acceptable by Chinese older adults to raise discussions regarding end-of-life matters., Practice Implications: A game can be an ice-breaking tool to increase self-efficacy towards communicating end-of-life care preferences with surrogates, but follow-up support is needed to facilitate the uptake of ACP behaviours., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Health literacy is the foundation for discussing and reaching decisions regarding future care in advance care planning (ACP). Objectives: This cluster randomized controlled trial compared the effects of a video decision aid with those of verbal narratives accompanied by photos in preparing community-dwelling Chinese adults for ACP. Setting and Subjects: Adults aged 60 years or older who were capable of communicating and decision making ( n  = 182). Methods: The study was conducted in eight community centers in Hong Kong from April to December 2018. The primary outcome was readiness for ACP. Secondary outcomes included knowledge of and decisional conflict regarding end-of-life care. Results: In both groups, significant improvements were noted in the readiness to discuss (β = 0.52, 95% confidence interval [CI] = 0.18 to 0.87, p  = 0.003) and document (β = 0.52, 95% CI = 0.13 to 0.90, p  = 0.008) end-of-life care preferences and knowledge (β = 0.85, 95% CI = 0.50 to 1.21, p  < 0.001); in addition, decisional conflicts significantly decreased (β = 0.87, 95% CI = 0.49 to 1.25, p  < 0.001). The video group demonstrated a greater improvement than the verbal group only in the knowledge score (β = 0.55, 95% CI = 0.08 to 1.02, p  = 0.023). Conclusions: The findings showed that both video decision aids and verbal narratives accompanied by photos are effective ways to prepare older Chinese adults for ACP, although the video format was more effective for knowledge transfer. More work is needed to evaluate the sustained effects of these education interventions. Clinical Trial: This trial was registered at ISRCTN14628950.

Background: Advance care planning (ACP) is highly relevant for people with early-stage dementia to communicate their care preferences for serious illness conditions with their family caregivers before they become mentally incapacitated., Methods: A multi-centre, quasi-experimental study was conducted to test the feasibility and acceptability of a theory-guided, dyadic ACP intervention ('Have a Say' programme) among participants with early-stage dementia-family caregiver dyads. The feasibility of the trial design, intervention procedures, subject recruitment and retention, and study instruments were assessed. Study outcomes were measured at baseline (T0), immediately after the intervention (T1), and at 1 month (T2) and 3 months post-intervention (T3). Acceptability of the intervention was determined by the satisfaction score, completion rate and qualitative interviews as process evaluation with a purposive sample of participants and ACP facilitators. Generalised estimating equations were performed to examine differential changes between groups over time, with covariates adjusted., Results: Subject recruitment from five elderly community centres yielded a recruitment rate of 60% and resulted in 36 client-caregiver dyads. The intervention was acceptable to the dyads, with a mean satisfaction score of 4.4 out of 5 and completion rate of 94.4%. The attrition rates at T1, T2, and T3 were 8.3%, 13.9%, and 19.4%, respectively. The intervention group reported a significantly greater improvement in the readiness for ACP at T1, self-efficacy for ACP at T3, and dyadic concordance on end-of-life care preferences at all time points than the control group, but not on depressive symptoms. Family caregivers in the intervention group reported a significantly higher caregiving burden at T2 than the control group. The qualitative findings revealed that triadic involvement of and trusting relationships among the dyads and ACP facilitators, and documentation of clients' views are the programme strengths, while the structured format and discussion about medical issues posed implementation challenges., Conclusions: This ACP intervention and trial design were feasible and acceptable to the dyads. Several refinements were identified, including adding a nurse-led group-based session for information giving, allowing flexibility in arrangement, and adding measure of ACP engagement of family caregivers. A rigorous trial to test the effects of the ACP intervention is warranted., Trial Registration: Retrospectively registered on 14/08/2020 at clinicaltrials.gov (Identifier: NCT04513106)., (© 2023. The Author(s).)

Background: Gamification has been adopted in the health care field for broaching sensitive topics and increasing motivation for behavior changes. Games developed to stimulate discussion surrounding end-of-life issues, and thereby promoting advance care planning also emerged., Aim: The aim is to integrate the quantitative evidence and qualitative evidence to understand the effectiveness of and experience with games for advance care planning., Design: A mixed-methods systematic review and meta-analysis (PROSPERO ID: CRD42020163312) was undertaken. Joanna Briggs Institute Critical Appraisal tools were used for quality appraisal. Data were synthesized and pooled for meta-analysis or meta-aggregation when appropriate., Data Sources: We searched MEDLINE, CINAHL, EMBASE, PsycINFO, Cochrane Library, WanFang, China Knowledge Resource Integrated Database, and Chinese Biomedical Literature Database from the inception of the databases for qualitative, quantitative, and mixed-method studies., Results: Eleven articles of ten studies were included, six of which were feasibility studies. The quality of the quantitative component of most included studies (7/8) was rated as low, and the qualitative component of most included studies (7/8) was rated as moderate. The meta-analysis showed that games for advance care planning are effective to increase self-efficacy, readiness, knowledge, and process of advance care planning behaviors. The meta-aggregation showed that games for advance care planning are highly acceptable and the participants perceived the game experience as fun and enjoyable., Conclusions: Advance care planning games seem to be a promising intervention for increasing the uptake of advance care planning behaviors. Well-designed randomized controlled trials evaluating the effectiveness of games for advance care planning are needed in the future.

Background: Training has been found effective in improving healthcare professionals' knowledge, confidence, and skills in conducting advance care planning (ACP). However, the association between training and its actual practice in the clinical setting has not been well demonstrated. To fill this gap, this paper examines the association between their readiness for ACP, in terms of perceived relevancy of ACP with their clinical work, attitudes toward and confidence and willingness to perform it, based on the Theory Planned Behavior and relevant training experiences., Methods: An online survey about experiences about ACP of healthcare professionals, including physicians, nurses, social workers, and allied healthcare professionals, currently working in hospital and community care in Hong Kong was conducted., Results: Of 250 respondents, approximately half (52.0%) had received ACP-related training. Those with relevant training reported significantly more positive in the perceived clinical relevance, willingness, and confidence in conducting ACP and different levels of agreement with 19 out of the 25 statements in a questionnaire about attitudes toward ACP than those without (ps ≤ 0.001-0.05). Respondents who received training only in a didactic format reported a significantly lower level of confidence in conducting ACP than did others who received a blended mode of learning (p = 0.012). Notwithstanding significant differences between respondents with and without relevant training, respondents generally acknowledged their roles in initiating conversations and appreciated ACP in preventing decisional conflict in surrogate decision-making regardless of their training experience., Conclusions: This paper revealed the association between training and higher level of readiness toward ACP among healthcare professionals. The findings showed that training is a predictor of their readiness for ACP in terms of perceived relevancy, willingness, and confidence. Those who had received training were less likely to consider commonly reported barriers such as time constraints, cultural taboos, and avoidance among patients and family members as hindrances to ACP implementation.

Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Context: Self-efficacy and readiness for advance care planning (ACP) is underresearched in the Chinese population given that these are novel concepts in the culture., Objectives: To translate the self-efficacy and readiness subscales of the ACP Engagement Scale into Chinese using the Brislin's Model and test its psychometric properties in Chinese older adults., Methods: Content validity and face validity were established based on the views of a group of experts and older adults. Then, a survey was conducted with a convenience sample of 204 community-dwelling older adults. Convergent validity was evaluated using Pearson's correlation coefficients with the SURE test, a decisional conflict scale. The scores between older adults who had hospitalization experience in the previous year and those who did not have were compared to examine discriminant validity., Results: The findings showed that the Chinese subscales had good internal consistency (Cronbach's α 0.94-0.97) and acceptable one-week test-retest reliability (intraclass correlation coefficient 0.66-0.70). There was a significantly high correlation between the self-efficacy and the readiness subscales (r = 0.809; P < 0.01) and moderate correlation between the two subscales and the SURE test (r = 0.509-0.587; P < 0.01). Discriminant validity was supported by significant differences between older adults who had hospitalization experience in the last year and those who did not have (P < 0.05)., Conclusion: The Chinese readiness and self-efficacy subscales of the ACP Engagement Survey are valid and reliable tools for assessing the preparedness of the Chinese older adults for ACP., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Aim: To examine the effect of a video-supported nurse-led advance care planning to frail geriatric patients on end-of-life decision-making outcomes in patients and their carers., Design: This is a double-blinded randomized controlled trial with parallel arms., Methods: The protocol was approved by the Institutional Review Board of the participating hospital on 1 August 2018. Frail elders and their carer if any are enrolled during hospitalization, and undergo randomization after discharged. The intervention group receives a 2-week video-supported nurse-led advance care planning programme (N = 149) while the control group receives a 2-week health education program at home (N = 149). Follow-up surveys via telephone at 1 and 6 months measure outcomes regarding end-of-life decision-making from both the patients and the carers., Conclusion: Advance care planning discussion is to understand patient's values, preferences and treatment for care on their anticipation of future deterioration. Treatment options for end-of-life care may not be well-received especially elders because in the discussion process, technical medical terms are presented in an abstract, hypothetical way that are hard to understand. The present study aims to evaluate the effect of a nurse-led advance care planning supplementing with a video showing end-of-life treatment options to promote end-of-life care decision-making among frail geriatric patients., Impact: The results will help identify effective elements of advance care planning and inform the development of an evidence?based structured advance care planning intervention in response to the need for quality end-of-life care., Trial Registration: Chinese Clinical Trial Registry ChiCTR-IOR-17012341., (© 2019 John Wiley & Sons Ltd.)

Background: Although evidence increasingly demonstrates the effects of advance care planning, the relevant studies are of questionable quality, and lack consensus regarding when and with whom to initiate the conversation., Objective: To examine the effects of a structured, nurse-led post-discharge advance care planning programme on congruence between the end-of-life care preferences of the patient and family members, decisional conflicts and the documentation of care preferences., Design: A two-arm parallel-group randomised controlled trial., Participants: A total of 230 dyads comprising community-dwelling patients screened by the Gold Standards Framework Prognostic Indicator Guidance and their designated family members., Methods: Patients in the experimental group participated in a structured advance care planning programme administered by a trained nurse during three weekly home visits following hospital discharge. In contrast, the post-discharge home visits provided to the control group focused on self-care management as attention control. The study outcomes were the dyadic congruence regarding end-of-life care preferences, the patients' level of decisional conflict regarding end-of-life decision-making and the documentation of these preferences at baseline and 1 and 6 months after enrolment. Generalised estimating equation models were used to compare changes in the outcomes between the groups across time., Results: At baseline, few participants had ever heard of advance directives (12/460, 2.6%) and few patients had ever discussed end-of-life issues with family members (34/230, 14.8%). After six months, the experimental group exhibited a greater increase in dyadic congruence regarding various end-of-life care preferences than the control group (Ps < 0.04). The experimental group also exhibited a greater improvement in decisional conflict at 6 months relative to the control group (P = 0.003). However, the groups did not differ significantly in terms of changes in any outcomes after one month. The experimental group had significantly higher rates of completion of advance directives and electronic medical record documentation of do-not-attempt cardiopulmonary resuscitation orders than the control group., Conclusions: This study showed that a nurse-led structured advance care planning programme could effectively improve dyadic congruence regarding end-of-life care preferences, reduce patients' decisional conflict and increase the documentation of care preferences. The findings underscored the importance of supporting nurses to introduce advance care planning at an earlier time that enable patients with sufficient time to contemplate end-of-life issues, empower patients to deliberate their choices and engage patients and their family members in open discussion., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Abstract Background Advance care planning (ACP) is highly relevant for people with early-stage dementia to communicate their care preferences for serious illness conditions with their family caregivers before they become mentally incapacitated. Methods A multi-centre, quasi-experimental study was conducted to test the feasibility and acceptability of a theory-guided, dyadic ACP intervention (‘Have a Say’ programme) among participants with early-stage dementia–family caregiver dyads. The feasibility of the trial design, intervention procedures, subject recruitment and retention, and study instruments were assessed. Study outcomes were measured at baseline (T0), immediately after the intervention (T1), and at 1 month (T2) and 3 months post-intervention (T3). Acceptability of the intervention was determined by the satisfaction score, completion rate and qualitative interviews as process evaluation with a purposive sample of participants and ACP facilitators. Generalised estimating equations were performed to examine differential changes between groups over time, with covariates adjusted. Results Subject recruitment from five elderly community centres yielded a recruitment rate of 60% and resulted in 36 client–caregiver dyads. The intervention was acceptable to the dyads, with a mean satisfaction score of 4.4 out of 5 and completion rate of 94.4%. The attrition rates at T1, T2, and T3 were 8.3%, 13.9%, and 19.4%, respectively. The intervention group reported a significantly greater improvement in the readiness for ACP at T1, self-efficacy for ACP at T3, and dyadic concordance on end-of-life care preferences at all time points than the control group, but not on depressive symptoms. Family caregivers in the intervention group reported a significantly higher caregiving burden at T2 than the control group. The qualitative findings revealed that triadic involvement of and trusting relationships among the dyads and ACP facilitators, and documentation of clients’ views are the programme strengths, while the structured format and discussion about medical issues posed implementation challenges. Conclusions This ACP intervention and trial design were feasible and acceptable to the dyads. Several refinements were identified, including adding a nurse-led group-based session for information giving, allowing flexibility in arrangement, and adding measure of ACP engagement of family caregivers. A rigorous trial to test the effects of the ACP intervention is warranted. Trial registration Retrospectively registered on 14/08/2020 at clinicaltrials.gov (Identifier: NCT04513106).