Patient, family, and healthcare provider experiences in advance care planning: a qualitative study

Abstract

Background: Advance care planning (ACP) aligns care with patients’ values and improves end-of-life outcomes. Yet uptake remains limited and frequently crisis-triggered, particularly in collectivist contexts where family interdependence and emotional tolerance shape participation. Empirical understanding of how ACP is experienced across patients, families, and healthcare providers in non-Western settings remains limited. Objective: To explore how patients, family caregivers, and healthcare providers experience and negotiate participation in ACP within a Thai palliative care context. Design: Qualitative study using reflexive thematic analysis. Setting: A university hospital in Bangkok, Thailand. Participants: Thirty participants: 10 patients with life-limiting illness, 10 family caregivers, and 10 healthcare providers. Methods: Semi-structured interviews were conducted at a palliative care center between January and October 2025. Interviews were transcribed verbatim, translated using meaning-based equivalence, and analyzed inductively using reflexive thematic analysis. Results: Four themes (10 subthemes) conceptualized ACP as a relationally negotiated, culturally embedded practice. (1) Timing and pathways: emotional, familial, and structural readiness shaped when ACP became possible, most often during clinical crises. (2) Values and visions of a good death: comfort, peace, and minimizing burden guided preferences, while caregiving and resource constraints limited feasibility. (3) Communication as relational positioning in ACP: gentle honesty and paced disclosure fostered engagement; decisions were negotiated within family circles; physicians typically initiated ACP, while nurses sustained relational continuity. (4) Structural conditions shaping the possibility of ACP: hierarchy, workload, limited training, and constrained community support restricted proactive implementation, reinforcing reactive patterns. Conclusion: ACP in this context functions as a relationally negotiated practice contingent upon alignment across emotional, familial, and structural readiness. Crisis initiation reflects misalignment across these domains rather than cultural resistance alone. Strengthening culturally attuned communication, family-centered engagement, interdisciplinary role clarity, and structural support may enable earlier and sustained ACP dialogue.