Guided by Leininger's Theory of Culture Care, this hermeneutic phenomenological study explored how social and cultural contexts shape engagement in advance care planning (ACP) among people living with cancer in Taiwan. Semi-structured interviews were conducted with 26 stakeholders, including 8 patients, 7 family caregivers, and 11 healthcare providers, recruited from oncology and ACP outpatient clinics, inpatient wards, and home care services at a tertiary medical center. Data were audio-recorded, transcribed verbatim, and analyzed using Naeem's six-step approach. Six interrelated influences on ACP engagement were identified: socioeconomic circumstances, prior experiences and personal background, religious beliefs and life values, relational dynamics with family and significant others, wider social norms, and political and legal requirements. These factors shaped whether ACP was seen as acceptable, when it was introduced, who was involved in decision-making, and how discussions were negotiated within families and with healthcare professionals. The findings show that ACP engagement in Taiwan is a relational, culturally embedded process. Culturally congruent, nurse-led ACP approaches that address relational, socioeconomic, and legal structural influences are needed to support family-centered cancer care.

Advance care planning of U.S. older adults with limited family ties: Evaluating the impacts of partnership trajectories and parental statuses.

To develop a machine learning model for predicting Taiwanese adults' intention to sign an advance directive (AD) and to identify the psychosocial, demographic, and system-level predictors relevant to culturally sensitive nursing. This study distinguishes between the reflective process of advance care planning (ACP) and the formal legal act of AD completion, addressing the need to understand cultural and system-level influences. This was a cross-sectional quantitative study. A survey was conducted with 1412 Taiwanese adults by using validated instruments, such as the Knowledge of Advance Care Planning Questionnaire and Advance Care Planning Attitude Scale. Data were analyzed using linear regression, random forest, and extreme gradient boosting models to predict the intention to sign an AD. A SHapley Additive exPlanations analysis was performed to interpret the model and investigate the effects of personal values and system-level barriers. The extreme gradient boosting model outperformed the other models, with mean absolute error and root mean squared error values of 1.68 and 2.13, respectively. The SHapley Additive exPlanations analysis highlighted attitude toward ACP as the strongest predictor of signing intention. In addition to psychosocial factors, system-level factors such as procedural unfamiliarity and high consultation costs emerged as key barriers. Furthermore, older age and a higher number of children were associated with a weaker intention to sign an AD, reflecting a preference for informal family consensus over formal legal documentation. Machine learning models effectively identify the interplay between personal attitudes, family dynamics, and institutional conditions that shape AD-related decision-making. The transition from ACP dialogue to formal AD signing is determined by both cultural values and structural factors. Nurses should adopt a dual-track strategy-supporting advance care planning through family-inclusive dialogues and serving as "system navigators" to help patients overcome legal and financial barriers to advance directive signing. Data-driven insights from the present study may inform precise, culturally responsive interventions that honor patient autonomy.

Survey of Canadian specialised palliative radiotherapy programs.

We investigated awareness and attitudes of Japanese university students toward end-of-life care and advance care planning (ACP) to inform campus-based educational programs and promote ACP dissemination across generations. A cross-sectional survey was conducted among 753 students at a university specializing in medical and welfare sciences. Participants completed a questionnaire assessing preferences for disclosure of terminal diagnoses, treatment decisions, and preferred place of death. Academic departments were classified into Medical sciences (n = 629) or Welfare sciences (n = 102), and group differences were analyzed using the chi-square test. Among 731 students, approximately 90% desired self-disclosure of a terminal diagnosis, whereas only 50.5% preferred disclosure to a spouse. While no group differences existed for disclosure preferences, place of death preferences significantly differed: medical students preferred home (80.8%) more frequently than welfare students (69.6%). Regarding end-of-life care, medical students were significantly less likely to choose aggressive interventions (e.g., ventilation, surgery) than welfare students. Conversely, welfare students were less likely to prefer artificial nutrition and hydration interventions than medical students. University students strongly favored disclosure of terminal illness and home-based end-of-life care. Differences between medical and welfare students likely reflect variation in familiarity with medical interventions. These findings underscore the importance of providing young adults with opportunities to consider ACP and engage in informed decision-making and dialogue with family members, thereby supporting person-centered care.

Advance care planning (ACP) is critical for communicating patients' preferences for future medical care, especially in geriatric populations. Despite the acknowledged importance, completion rates remain low. We aimed to increase ACP in a geriatric primary care clinic (geri-PCC) using a trainee-led educational intervention. Retrospective analysis of a quality improvement intervention. In total, 498 patients, > 60years old with no advance directives (AD) or Portable Medical Orders (POLST) were seen in the geri-PCC during the intervention period. Sixty-five received the intervention while 433 did not. We incorporated an ACP education session led by medical trainees into the geri-PCC workflow 3/2023-4/2023. New AD (includes durable power of attorney for healthcare (dPOA) and Living Will (LW)) and POLST captured in the EMR, ICD-10 codes billed for ACP/goals of care (GOC) were compared between the intervention and standard care groups during 6 months following the intervention period. Secondary logistic regression analyses adjusted for age, gender, mood disorder, and cognitive impairment when evaluating the intervention's association with primary outcomes. The intervention group had more new dPOA forms (13.8% vs 5.3%, p = 0.025) and ACP/GOC codes (32% vs 13%, p < 0.001). These findings remained significant after adjusting for age, gender, mood disorder, and cognitive impairment (dPOA OR = 2.96, 95% CI 1.24-6.59, p = 0.010; ACP/GOC OR 3.07, 95% CI 1.67-5.52, p < 0.001). Cognitive impairment was associated with more completion of POLST (OR = 3.29, 95% CI 1.15-11.0, p = 0.035) but less completion of LWs (OR = 0.34, 95% CI 0.13-0.79, p = 0.018). Incorporating an ACP education session led by medical trainees was associated with increased AD documentation in the EMR and increased ACP/GOC codes billed in our geri-PCC. The emergence of cognitive impairment as a predictor of POLST completion needs further exploration.

Although hematology/oncology (H/O) topics are essential for clinicians, many internal medicine (IM) residents perceive inadequate H/O education. This perception may be due to the lack of a standardized H/O curriculum. To address this gap, we aimed to achieve consensus about the most important H/O topics for IM residents to learn. In 2023, we conducted a 2-round modified Delphi study of IM generalists and H/O specialists at the University of California, San Francisco and Stanford University. In round 1, participants rated the importance of H/O topics on a 5-point scale (1 = very unimportant; 5 = very important). In round 2, participants viewed their own ratings vs. the group mean and could change their ratings. We used a content validity index (CVI, the percentage of respondents who rated the topic ≥ 4) of ≥ 75% to identify the most important topics. We calculated the effect sizes of between-group rating differences using Cohen's d. The round 1 and 2 response rates were 70% (92/132) and 77% (71/92), respectively. Ninety-one of the 239 topics met the CVI threshold (41 classical hematology, 14 malignant hematology, and 36 solid oncology), of which only 4 out of 91 (4%) had a large effect size, indicating agreement between generalists and specialists. There were 14 topics with a CVI of 100%, including deep venous thrombosis/pulmonary embolism, iron deficiency anemia, advance care planning, and management of end-of-life issues. With input from IM generalists and H/O specialists, we identified the most important H/O topics for IM residents, which can guide curriculum development.

Emergency departments (EDs) play a critical role in caring for the aging population, particularly those nearing the end of life. Despite advances in integrating palliative care resources in the ED, targeted research on the impact of hospice and palliative care (HPC) consultations for older adults in ED settings remains limited. This systematic review protocol assesses the effects of ED-initiated HPC consultations on health outcomes and the quality of care for older adults. The objective of this systematic review is to synthesize the available evidence on the effectiveness of ED-initiated HPC consultations on the provision of advance care planning among older adults (≥60 years). Our review will focus on assessing several secondary outcomes, including mortality, hospital admissions, length of stay, repeat health service use, costs, and satisfaction levels among patients, caregivers, and clinicians. Following the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) reporting guidelines, our protocol outlines a comprehensive review of published studies. Systematic searches will be conducted in databases such as Medline, EMBASE, PubMed, Cochrane Trials database, and Web of Science from inception to present. Studies will be selected if they involve randomized, quasi-randomized, or observational designs examining the effectiveness of HPC interventions in the ED for older adults. Title, abstract and full text screening, risk of bias evaluation, and grading of the evidence will be completed independently and in duplicate by a group of emergency medicine and palliative care researchers. If feasible, a meta-analysis will be conducted using a random-effects model to evaluate the outlined outcomes. We will report descriptive statistics to describe the body of literature and we will pool absolute risk differences along with corresponding 95% CIs. We will also report on study risk of bias and certainty of the evidence. Despite the rapid growth of emergency medicine and HPC literature, a focused systematic review on the geriatric ED population remains absent. Our work not only fills a vital gap in the literature related to ED-initiated HCP consultations for older adults, but it sets the stage for significant future advancements in the care of older adults in the ED.

There is a lack of understanding of the landscape of advance care planning (ACP) in the Asia Pacific, and to our knowledge, no previous comparative study has been performed. This study sets out to map the current landscape of ACP implementation across member sectors within the Asia Pacific Hospice Palliative Care Network (APHN). This was a cross-sectional survey of purposively sampled experts and leaders, with at least 5 years of experience in ACP-related practice, from the member sectors of APHN. There is a rich diversity of approaches to ACP implementation, including its conceptualisation, time of initiation and accessibility across various sectors in the Asia Pacific region. The implementation of ACP as a national or organisational programme is associated with increased perceptions of its uptake and accessibility, particularly within Taiwan, New Zealand and Singapore. In some Asian sectors such as in Hong Kong, India, Indonesia, South Korea, Malaysia, Sri Lanka, Thailand and Vietnam, a more family-led ACP process exists, even if the patient has capacity to make healthcare decisions. Most sectors reported top barriers to ACP as a lack of public awareness (9 out of 15 sectors) and lack of empowerment of healthcare professionals (13 out of 15 sectors) as well as social taboo (11 out of 15 sectors). National and organisational support for the ACP process, cultural competency in ACP and engagement efforts to raise awareness and address barriers to ACP are important considerations in ACP implementation in the Asia Pacific.

Palliative care improves the quality of life of people living with life-limiting conditions and their families; however, global access remains constrained by workforce shortages and late referrals. Artificial Intelligence (AI) has been proposed as a scalable solution for optimising the identification of needs, supporting clinical decision-making, and enhancing care delivery. However, real-world evidence of the application of AI in palliative care remains sparse, particularly regarding its impact on quality of life, quality of care, and associated practical, technical and ethical challenges. A scoping review was conducted following the Joanna Briggs Institute methodology and the PRISMA-ScR checklist. Five databases (the ACM Digital Library, CINAHL, Cochrane Central, PubMed and Web of Science) were searched between September and October 2025. Studies reporting the use of AI to facilitate or enhance palliative care delivery in adults were eligible. Four reviewers independently screened the records, and two reviewers extracted the data using Covidence software. A narrative synthesis was then performed. Fifteen studies, published between 2021 and 2025, were included. Fourteen originated from Global North settings (USA 5, Germany 2, Japan 2, Taiwan 2, UK 1, Spain 1 and Cyprus 1) and one from Iran. Conceptually, AI applications fall into three domains: (1) early identification of palliative care needs, (2) symptom assessment and management and (3) clinical decision support for care conversations. Fifteen studies (100%) reported or discussed quality of care outcomes, most commonly prognostic performance, usability and referral/conversation rates, and only two (13.3%) directly addressed quality of life. Effectiveness was consistently positive, with four randomised controlled trials demonstrating superiority over usual care in referrals, advance care planning, pain control and quality of life domains. Practical barriers were centred on workflow integration and resource demands, while technical limitations include data quality, generalisability, and interpretability. Ethical discourse is underdeveloped, with major gaps in the principles of AI governance. AI shows potential to improve prognostic accuracy, trigger earlier involvement of palliative care specialists and support symptom management. However, this evidence is geographically skewed, methodologically immature and ethically underdeveloped. Future research must prioritise diverse global settings, patient-reported quality of life outcomes, participatory co-design and systematic ethical governance to ensure equitable implementation.

Prognostic information plays a key role in decision-making in adult intensive care units (ICUs), but its influence on advance care planning, treatment limitation and palliative-care integration depends on organisational, legal, cultural and relational factors. This review focuses on how prognostic information is used in decision-making processes. This realist review will explore how, why, for whom and in which ICU contexts prognostic information impacts care planning. Following Realist and Meta-narrative Evidence Syntheses (RAMESES) publication standards for realist syntheses, we will iteratively develop an initial programme theory (IPT) and refine context-mechanism-outcome (CMO) configurations through staged database and grey literature searches, selecting sources based on relevance and rigour, performing theory-driven extraction and applying realist synthesis strategies (juxtaposition, reconciliation, adjudication and consolidation). Stakeholders, including ICU and palliative care clinicians, caregiver representatives and ethics/policy advisors, will contribute to shaping IPT development, CMO refinement and interpretation. Reporting will also adhere to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines; the completed checklist is provided as Supplementary File S1. Ethical approval is not required (secondary analysis). Findings will be disseminated through peer-reviewed publications, conference presentations and stakeholder-targeted briefs for clinicians, policymakers and professional bodies. Open Science Framework (OSF: https://osf.io/6qu8x).

ObjectiveThis systematic review synthesizes randomized controlled trial evidence on the effectiveness of nurse-led ACP interventions for patients with advanced cancer.MethodsWe searched PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register from inception to January 2026. Eligible studies were randomized controlled trials (RCTs) evaluating nurse-led ACP interventions in adults with advanced or metastatic cancer. Two reviewers independently screened records, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool. A narrative synthesis was performed due to clinical and methodological heterogeneity precluding meta-analysis.ResultsSix studies (7 publications; N = 2816) met inclusion criteria, conducted in the United States, South Korea, and six European countries. Nurse-led ACP interventions consistently increased advance directive completion (adjusted odds ratios 2.5-5.3) and end-of-life conversation rates vs usual care. One trial showed facilitated nurse-led ACP outperformed patient-directed approaches in ACP engagement (adjusted difference 0.25; 95% CI 0.10-0.40; P = .001). Quality of life outcomes were mixed; most trials showed no significant difference at 3 months, though higher-intensity interventions trended toward greater benefit. Overall risk of bias was low to moderate.ConclusionsNurse-led ACP interventions are feasible and effective in improving ACP engagement and end-of-life outcomes for patients with advanced cancer. Successful implementation requires standardized training, adequate intervention intensity, and systematic follow-up. Future trials should use validated patient-reported ACP measures and explore optimal timing and delivery methods.

Evidence shows that advance care planning has the potential to reduce involuntary admissions and empower service users. The perinatal period is a time of heightened risk of relapse of mental illness, and, in this context, many perinatal mental health services routinely offer pre-birth mental health care planning meetings. We aimed to explore the experience of perinatal mental health service users and their partners following a pre-birth planning meeting and the writing of a perinatal care plan that included advance care plans for birth, postpartum and in case of crisis. We interviewed pregnant perinatal mental health service users and their partners at two large, urban maternity hospitals in Dublin, Ireland. We used thematic analysis to identify key themes relevant to their experiences of pre-birth planning meetings and written perinatal mental health care plans. Ten service users and three partners were interviewed. We identified five themes: theme 1, Hoping for change; theme 2, A wish to be heard; theme 3, Individualised care; theme 4, Security of 'a plan in place' and theme 5, Role of the support network. Women and their partners value pre-birth planning meetings and these should routinely be offered within services, with consideration as to the size and timing of the meeting, and who is in attendance. These findings are relevant to general adult and liaison psychiatrists who should also incorporate advance care planning into routine practice.

ObjectiveTo identify and synthesize the available evidence on the impact of advance care planning on decision-making and end-of-life care.DesignA scoping review was conducted following the Joanna Briggs Institute methodology. The results were grouped into thematic categories and presented in accordance with the PRISMA-ScR guidelines.Inclusion CriteriaDocuments published between 2006 and 2026 in English, Spanish, and Portuguese were included, provided they were available in full text and addressed the research question.Information SourcesThe PubMed, Scopus, Web of Science, and BIREME databases were used. Additionally, the snowball sampling method was employed to expand the search.ResultsA total of 2816 records were identified through database searches and secondary tracking, of which 30 were selected for the final review. The identified impacts were organized into a conceptual framework comprising five interrelated dimensions: care congruence, healthcare utilization, economic and cost outcomes, family and caregiver impact, and patient quality of life. Each category is enriched by a set of interrelated components that describe various clinical, psychosocial, and financial outcomes reported in the literature.ConclusionsAlthough advance care planning is not a new concept, this review provides an updated and integrated framework that highlights five interrelated domains of impact fundamental to the quality of end-of-life care. These findings suggest the potential value of considering ACP within patient-centered and value-based care models, while underscoring the relevance of future research aimed at informing the sustainability and humanization of end-of-life care.

LGBTQ+ individuals face grieving processes complicated by minority stress, structural discrimination, and fears related to disclosure of their sexual orientation or gender identity, which leads to disenfranchised grief within healthcare systems that remain heteronormative. Recent literature on palliative care highlights inequities in access, a lack of recognition of chosen families, and gaps in professionals' LGBTQ+ cultural competence. To explore research published between 2021 and 2026 on grief and bereavement-related experiences among LGBTQ+ adults in healthcare and palliative care settings, identifying the main topics addressed and knowledge gaps relevant to clinical practice. A scoping review was conducted following the framework of Arksey and O'Malley and the recommendations of the Joanna Briggs Institute and reported according to PRISMA-ScR. Original articles were searched for in 6 databases (February 2026). Independent double screening (k = 0.87) with removal of duplicates. Primary empirical studies on grief and bereavement-related experiences in LGBTQ+ adults in healthcare or palliative care settings were included, including studies on end-of-life communication, advance care planning, disclosure processes, and bereavement-related support when they provided identifiable primary data. Data were extracted using structured templates and analyzed through inductive thematic analysis. Seven primary empirical studies were included, with qualitative designs predominating. The evidence was mainly produced in English-speaking countries. Four main themes were identified: minority stress, complexities of disclosure, disenfranchised grief, and gaps in professional training. Critical gaps included underrepresentation of transgender people, a scarcity of quantitative data, an absence of intersectional perspectives, and concentration in Western contexts. Grief and bereavement-related experiences of LGBTQ+ adults in healthcare and palliative care settings appear to be profoundly shaped by structural dynamics of stigma, the invisibility of the chosen family, and training deficits in LGBTQ+ cultural competence. These findings suggest the need to develop institutional protocols sensitive to disclosure preferences, formally recognize the chosen family in end-of-life decisions, and incorporate mandatory training in LGBTQ+ competencies into curricula and continuing education programs. Future research should prioritize longitudinal and interventionist designs, intersectional approaches, and studies in non-Western contexts.

There is no consensus on an age cut-off for being considered elderly, but the majority of patients with heart failure (HF) have an advanced age. The lifetime risk for developing HF is ∼25%, with a sharp increase in incidence after the age of 70. The lifetime risk for men and women is almost equal, but women exhibit a higher propensity towards developing HF with preserved ejection fraction, whereas men are more prone to HF with reduced ejection fraction. During the biological ageing process, several systemic and local pathophysiological alterations impact the myocardium, including impaired autophagy and proteostasis, mitochondrial dysfunction, and oxidative stress, as well as cellular senescence, clonal haematopoiesis of indeterminate potential, and chronic low-grade inflammation or inflammaging. Collectively, these changes compromise cardiac energy homeostasis and promote cell loss and dysfunction, increasing the risk of HF. Despite their relevance, these ageing-related mechanisms are hitherto not addressed by guideline-recommended medical therapy. Guideline-recommended medical therapy remains the cornerstone of HF treatment across age groups, including in elderly patients who tolerate it. However, a high burden of comorbidities and several features specific to advanced age, such as low blood pressure and frailty, often preclude full-dose guideline-recommended medical therapy. Similarly, the risk-benefit ratio of device therapies needs careful consideration in light of competing non-cardiac risks due to comorbidities that are prevalent in this population. Finally, HF is a mortal condition, and advanced care planning and end-of-life decisions should be discussed in a timely manner in elderly patients.

Many people living with dementia (PLWD) with advancing disease are unable to access office-based care for primary and dementia care. Nurse practitioners (NPs) could fill this gap. The objective of the current review was to determine patient, caregiver, and health care system outcomes of home-based dementia care models that use NPs. A scoping review was completed using the Arksey and O'Malley Framework. Two independent reviewers completed title/abstract and full-text screening. Data were extracted using Microsoft Excel. A thematic synthesis was completed to summarize findings. The search yielded 4,410 citations; 17 articles met inclusion criteria, reporting on 10 models. Outcomes included high-quality care, decreased emergency department use, decreased acute care length of stay, delayed facility-based long-term care placement, and high rates of advanced care planning and transition to palliative care. Home-based dementia care models that use NPs for longitudinal care have the potential to support aging in place.

The ethical terrain surrounding feeding at the end-of-life is emotionally charged and complex. In the literature, the recently introduced notion of "minimal comfort feeding" (MCF), defined as deliberate limitation of feeding or hydration, given only in response to visible signs of hunger or thirst, for a patient with a longer prognosis, has been proposed as a comfort measure at the end of life and as an alternative to voluntarily stopping eating and drinking (VSED) in advance care planning. However, the same term may be applied to two morally distinct acts: 1) providing comfort in the context of active dying, and 2) a hastening death. In this paper, we argue for conceptual clarity around these two practices and their ethical valence, drawing on an Anscombean-Thomistic virtue ethics framework that deals with moral evaluation of human action and the doctrine of double effect. We present two clinical cases highlighting each of these ethical scenarios. Through the cases, we show how intentionality and some circumstances such as timing critically shape the morality of the act. We propose a new nomenclature with the aim of fostering ethical clarity of the morally distinct acts: "proportionate comfort feeding" (PCF) for MCF where nutrition and hydration is provided for comfort with the understanding that it may hasten death but is its foreseen, unintended outcome, and "minimal feeding to hasten death" (MFHD) for cases where MCF is chosen with the specific intention to hasten death.

Sex differences in intensive care treatment and mortality are well documented, but the timing of decisions to limit treatment remains unclear. We investigated whether sex differences in decisions to limit treatment arise at ICU admission or during the ICU stay. Nationwide cohort study using the Swiss Minimal Dataset for Intensive Care Units, including adult (≥ 18 years) ICU admissions between 2016 and 2024. Two adjusted logistic regression models assessed treatment limitations documented at ICU admission and those occurring later among patients admitted without limitations. Among 654,660 ICU stays, treatment limitations at admission were more common in women than men (12.0% vs. 8.6%), whereas rates during the ICU stay were similar (5.5% vs. 5.5%). Female sex was independently associated with limitations at admission (aOR 1.26, 95% CI 1.24-1.28) but only weakly associated with later limitations (aOR 1.10, 95% CI 1.08-1.13). Differences at admission varied by diagnosis and were most pronounced in trauma and cardiovascular conditions. Women more often had ceiling-of-care decisions and documented patient wishes, whereas men more frequently underwent withdrawal of life-sustaining therapies and physician-driven decisions. Mortality was highest with limitations at ICU admission and lowest without limitations, with minimal sex differences within categories. In Switzerland, sex differences in treatment limitations occur mainly at ICU admission and vary across diagnoses. These findings suggest that differences may reflect early triage heuristics, societal norms influencing advance care planning, and potential implicit biases under prognostic uncertainty. Structured goal-of-care discussions at ICU admission may help promote consistent and equitable decision-making.

Advance care planning has proven to be beneficial to medical care as it elicits patient preferences at the end of life, yet Indigenous populations have low rates of participation. This gap map scoping review serves to assess the current literature regarding the prevalence of advance care planning and palliative care characteristics in Indigenous populations of North America and Oceania. Articles were identified from searches performed in five databases spanning the period from 2013 to 2023. Twenty-eight articles met the inclusion criteria, representing studies conducted in the United States (n = 15), Canada (n = 2), New Zealand (n = 7), and Australia (n = 4). The included articles varied in study design, comprising qualitative (n = 16), observational (n = 7), mixed method (qualitative and quantitative) (n = 4), and interventional (n = 1). Two major findings endorsed across studies were (1) a high frequency of family involvement in end-of-life decision making and (2) awareness of culturally unsafe end-of-life services, creating hesitancy and mistrust. These results map the gaps in the existing research literature exploring the needs and preferences of Indigenous peoples in end-of-life decisions, palliative care, and advance care planning while highlighting a paucity of known effective interventions for Indigenous people.