Implementation, Processes and Outcomes of Advance Care Planning: A Culturally and Contextually Appropriate Programme Theory Developed in Chinese Long-Term Care Facilities

Background: Despite advance care planning (ACP) being associated with positive outcomes for residents in long-term care facilities (LTCFs), the causal pathways between ACP and these outcomes are context-specific and less understood. This lack of clarity can hinder the cultural adaptation and evaluation of ACP interventions. This study aimed to develop a programme theory that outlines the causal pathways through which the ACP is hypothesised to achieve impacts in Chinese LTCFs, with a focus on understanding its implementation, processes and outcomes. Methods: Exploratory qualitative design incorporating Theory of Change (ToC) methodology. Two ToC workshops (one face-to-face and one online) were held with 37 participants experienced in caring for residents or older people. The process was informed by a realist review and primary qualitative study. A programme theory was developed through thematic analysis, generating a ToC map depicting implementation, processes and outcomes of ACP in LTCFs. Results: The programme theory was constructed to outline the causal pathways of ACP in LTCFs, populating five ‘precondition’ domains: (1) buy-in from government and facility leadership, (2) availability of external and internal resource, (3) adequate training and awareness for public and facility, (4) identification of residents who are ready for ACP and (5) culturally sensitive communication. Nine intervention components were identified that target preconditions, such as raising ACP awareness and providing staff training and mentoring. The potential impacts of ACP were identified, for example, fostering public attitudes towards a ‘good death’ and increasing public awareness and acceptance of palliative care. Conclusions: Our mid-range programme theory can serve as a heuristic tool, adaptable for context-specific ACP interventions in other countries, enhancing the likelihood of achieving intended impacts. In particular, intervention components focused on family involvement can be transferable to East Asian regions, where relational autonomy and family-centred decision-making are emphasised. The programme theory is ready for feasibility testing for residents in Chinese LTCFs. Patient or Public Contributions: We were guided by patient and public involvement members including two residents and one family member of a resident throughout the study. They supported the overall development of programme theory, including reviewing the theory and interpreting findings.