Implementing advance care planning with community-dwelling frail elders requires a system-wide approach: An integrative review applying a behaviour change model

Palliat Med. 2019 Jul;33(7):743-756. doi: 10.1177/0269216319845804. Epub 2019 May 6.


Background: Facilitating advance care planning with community-dwelling frail elders can be challenging. Notably, frail elders' vulnerability to sudden deterioration leads to uncertainty in recognising the timing and focus of advance care planning conversations.

Aim: To understand how advance care planning can be better implemented for community-dwelling frail elders and to develop a conceptual model to underpin intervention development.

Design: A structured integrative review of relevant literature.

Data sources: CINAHL, Embase, Ovid Medline, PsycINFO, Cochrane Library, and University of York Centre for Reviews and Dissemination. Further strategies included searching for policy and clinical documents, grey literature, and hand-searching reference lists. Literature was searched from 1990 until October 2018.

Results: From 3043 potential papers, 42 were included. Twenty-nine were empirical, six expert commentaries, four service improvements, two guidelines and one theoretical. Analysis revealed nine themes: education and training, personal ability, models, recognising triggers, resources, conversations on death and dying, living day to day, personal beliefs and experience, and relationality.

Conclusion: Implementing advance care planning for frail elders requires a system-wide approach, including providing relevant resources and clarifying responsibilities. Early engagement is key for frail elders, as is a shift from the current advance care planning model focussed on future ceilings of care to one that promotes living well now alongside planning for the future. The proposed conceptual model can be used as a starting point for professionals, organisations and policymakers looking to improve advance care planning for frail elders.

Keywords: Advance care planning; aged; behavioural change; communication; end-of-life care; frail elderly; systematic review.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Advance Care Planning / organization & administration*
  • Advance Care Planning / standards
  • Aged
  • Communication
  • Frail Elderly*
  • Humans
  • Implementation Science*
  • Independent Living*
  • Terminal Care