Navigating the path to planned endings: understanding Chinese older adults’ engagement with advance care planning through constructivist grounded theory

Abstract

Background

Advance care planning implementation reveals complex tensions between ethical principles and cultural-specific moral frameworks. Within the Chinese healthcare context, medical decision-making operates within a unique ethical landscape shaped by Confucian values, yet systematic ACP promotion in this context remains limited.

Objective

This study aims to (1) develop a grounded theory of older adults’ engagement with advance care planning in the Chinese context; (2) understand how participants navigate decision-making processes within China’s cultural and healthcare systems.

Design

The investigation employed Charmaz’s constructivist grounded theory methodology guided by Nie’s framework of Chinese medical ethics through a three-stage approach across diverse geographical regions in China.

Participants

Twenty-five participants (13 males/12 females) aged 60–95 years from representative regions of China.

Methods

Following Charmaz’s constructivist grounded theory methodology, data collection progressed from pre-experimental convenience sampling (3 participants), to Stage 1 purposive sampling (12), and Stage 2 theoretical sampling (13) until saturation. Analysis employed concurrent interviews and constant comparative methods guided by Chinese medical ethical principles.

Results

The analysis produced the substantive theory “Navigating the Path to Planned Endings,” encompassing three interconnected categories: Negotiating Death Discourse, The Locus of Decision, and Systemic Support Infrastructure. “The Locus of Decision” emerged as the core category where participants reconcile individual autonomy, filial obligations, and family harmony.

Conclusions

The theoretical framework reveals complex ethical processes through which Chinese older adults engage with advance care planning, highlighting the crucial role of moral agency where traditional values and modern bioethical principles intersect. These findings necessitate culturally sensitive ACP implementation approaches acknowledging family roles while upholding principles of autonomy and justice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-025-01278-2.

Introduction

Ethical foundations and theoretical tensions in end-of-life care planning

Advance care planning (ACP) represents a critical intersection of medical ethics and cultural values, raising fundamental questions about autonomy, beneficence, and justice in end-of-life care [1]. While healthcare systems increasingly recognize ACP’s role in promoting ethical decision-making and minimizing potentially harmful interventions, its implementation reveals complex tensions between universal ethical principles and culturally-specific moral frameworks [2]. These tensions become particularly pronounced in societies where traditional values create distinct ethical challenges for healthcare delivery [3]. The theoretical complexity of ACP implementation extends beyond mere procedural considerations, encompassing deeper philosophical questions about the nature of moral agency, the boundaries of individual autonomy, and the ethical legitimacy of collective decision-making frameworks in medical contexts.

Cultural epistemologies and moral frameworks in Chinese medical ethics

The Chinese healthcare context presents a unique ethical landscape where medical decision-making may operate within a collective framework shaped by Confucian values. These cultural norms position the family unit, rather than the individual, as the primary locus of medical decision-making [4], creating distinctive ethical challenges for healthcare providers attempting to balance respect for individual autonomy with cultural expectations. Traditional Chinese perspectives regarding death introduce additional moral complexities, deeply rooted in cultural beliefs that discussing death might bring misfortune [5]. These beliefs, fundamentally shaped by Confucian values of xiao (filial piety) and he (harmony), combined with strong family bonds, often lead to death being perceived as a collective family experience rather than an individual journey [6]. Consequently, discussions about end-of-life care remain largely taboo, presenting unique ethical tensions between traditional values and contemporary healthcare principles [7]. This cultural epistemology challenges Western bioethical paradigms that privilege individual autonomy, necessitating a more nuanced understanding of how moral agency operates within collectivist frameworks.

Contemporary Chinese medical ethics operates within a distinctive theoretical framework that integrates traditional Confucian virtues with modern biomedical principles, emphasizing ren (benevolence), li (propriety), and collective harmony alongside individual care [8]. Chinese healthcare providers are predominantly trained through a hybrid ethical model that combines the Chinese Medical Association’s ethical guidelines with traditional values of compassionate care and family-centered decision-making. This dual-framework training emphasizes virtuous character development, maintaining face and dignity, and preserving family relationships, while simultaneously incorporating contemporary medical principles of informed consent and patient safety. This complex cultural landscape requires healthcare providers to navigate intricate ethical terrain while maintaining therapeutic relationships and advocating for patient preferences.

Systemic implementation challenges and healthcare disparities

Despite China’s significant healthcare system development, a notable absence of systematic ACP promotion and public health education persists [9]. The current state of ACP awareness in China presents concerning gaps, with research demonstrating that 82.2% of advanced cancer patients have never heard of ACP concepts, highlighting the profound lack of public understanding regarding end-of-life planning options [10]. While legislative progress has emerged in certain regions, such as Shenzhen’s pioneering advance directive legislation, widespread implementation remains limited due to insufficient institutional support and inadequate integration with existing healthcare delivery systems. Within China’s healthcare system, hospitals remain the primary setting for end-of-life care, where medical resources for terminal patients are concentrated. Although “medical-nursing combined” facilities are increasingly promoted, and despite the potential for home-based care, limited family caregiving capacity and societal preferences continue to maintain hospitals as the dominant venue for elderly end-of-life care [11].

The structural inequities within China’s healthcare system create additional ethical complexities for ACP implementation. This fundamental lack of awareness impacts engagement among both healthcare providers and patients [12], while China’s diverse socioeconomic landscape, characterized by pronounced regional variations in healthcare resource distribution [13], presents moral challenges in providing equitable care across different contexts. The marked disparity between urban and rural areas fundamentally influences ACP accessibility, stemming from differences in healthcare infrastructure, insurance coverage systems, and economic resources. Rural residents particularly face substantial obstacles including prolonged travel times and elevated transportation costs when seeking specialized medical care, further complicating their ability to engage with ACP resources [13].

Current literature reveals critical ethical tensions, with healthcare professionals demonstrating limited understanding of ACP principles while implementation guidelines remain notably absent [14]. However, this knowledge gap raises concerns about providers’ preparedness to support patients in making informed end-of-life care decisions that align with both traditional Chinese ethical principles and cultural values. Institutional support varies significantly, with inadequate training and resource allocation creating substantial barriers [15]. Healthcare providers struggle with practical implementation aspects, including appropriate timing and approach strategies, particularly affecting their ability to facilitate ethically sound ACP discussions.

Theoretical gaps and research framework

While research has examined individual aspects of ACP implementation across cultural contexts, a significant gap exists in understanding how multiple factors collectively influence end-of-life care planning within Chinese healthcare environments. Previous studies have focused on isolated barriers rather than examining how cultural attitudes, family dynamics, and systemic constraints interact to shape moral decision-making. Given the need for culturally appropriate theoretical frameworks that integrate traditional Chinese medical ethical principles [8] while addressing contemporary healthcare challenges, this study adopts a grounded theory methodology to develop indigenous theoretical understanding that transcends Western bioethical paradigms.

This study employs constructivist grounded theory methodology developed by Charmaz [16] to address four key research questions: (1) How do Chinese older adults conceptualize end-of-life care planning within their cultural context? (2) What factors influence their decision-making processes regarding advance care planning? (3) How do family dynamics, cultural values, and healthcare characteristics interact to shape ACP engagement? (4) What theoretical framework explains how Chinese older adults navigate advance care planning decisions? The resulting theoretical framework aims to improve ACP understanding and implementation in Chinese healthcare settings by honoring indigenous ethical paradigms while addressing contemporary healthcare needs, thereby contributing to both cross-cultural bioethics scholarship and practical healthcare policy development.

Methodology

Aim

This study aims to develop a comprehensive grounded theory of older adults’ engagement with advance care planning in the Chinese context, informed by Nie’s (2013) traditional Chinese medical ethical principle, to understand how participants navigate decision-making processes within China’s unique cultural and healthcare systems.

Study design

The study employed Charmaz’s constructivist grounded theory methodology [16, 17] to explore older adults’ engagement with advance care planning. Unlike other grounded theory methodologies that presume the discovery of objective truths, this constructivist paradigm recognizes knowledge as contextually situated, acknowledging that data and analysis emerge through interactive processes embedded within specific social and cultural contexts. This epistemological position explicitly recognizes researchers’ interpretive roles while maintaining systematic analytical procedures, making it particularly suitable for understanding advance care planning through the cultural and social matrices that shape Chinese older adults’ decision-making processes. The methodology enables exploration when limited knowledge exists about a phenomenon, allowing theories to emerge from data rather than testing preconceived frameworks. This approach proved especially appropriate for examining the complex intersection of contemporary biomedical ethics and traditional Chinese values that characterize modern Chinese healthcare contexts. Our analysis was guided by Nie’s (2013) framework of Chinese medical ethics, which emphasizes the principles of ren (benevolence), li (propriety), xiao (filial piety), and he (harmony), facilitating our understanding of how participants navigate end-of-life decisions within these cultural-ethical dimensions.

The investigation proceeded through three stages: a preliminary research stage conducted in Hangzhou, followed by Stage 1 initial investigation and Stage 2 theory development across diverse geographical regions in China to ensure cultural and socioeconomic representation.

The preliminary stage served primarily to verify the feasibility of the research protocol and ensure the appropriateness of interview questions within the Chinese cultural context, without attempting to generate preliminary theoretical insights. This initial testing stage helped establish procedural clarity before proceeding to the main investigation stages. The overall research design is illustrated in Fig. 1. Throughout all stages, data collection incorporated in-depth interviews with elderly participants, complemented by non-participant observations of daily activities. Consistent with constructivist grounded theory principles, our analytical process involved simultaneous data collection and analysis, constant comparative methods, and theoretical sensitivity to cultural nuances. This iterative approach allowed for the emergence of theoretical insights grounded in participants’ lived experiences while acknowledging the socially constructed nature of advance care planning practices within contemporary Chinese healthcare systems.

Fig. 1.

Grounded theory research design

Sample and setting

The study recruited participants from multiple community service centers and nursing homes across representative regions of China (encompassing diverse geographical locations and ethnic populations) from March to May 2025. Initial contact was made through telephone screening using center registries and administrative records, followed by face-to-face meetings for detailed study information and informed consent. This approach ensured comprehensive access to the target population while facilitating rapport building with participants.

The sampling methodology followed a systematic progression across three distinct stages. Convenience sampling initiated the pre-experimental stage with three participants, enabling preliminary testing of research protocols and refinement of data collection instrument [18]. Subsequently, the stage 1 employed purposive sampling to recruit twelve participants, ensuring representation across diverse demographic and socioeconomic characteristics while facilitating the emergence of initial theoretical concepts [19]. The stage 2 utilized theoretical sampling, integral to grounded theory methodology [16], which guided the selection of thirteen participants, allowing for exploration and validation of emerging theoretical constructs through targeted recruitment of individuals whose experiences could illuminate specific aspects of the developing theory.

The study population demonstrated comprehensive representation across demographic and socioeconomic characteristics. Participants ranged in age from 60 to 95 years, with 13 males and 12 females comprising the study sample. Individual gender information was anonymized in data presentation to ensure participant confidentiality in accordance with ethical research standards. The sample demonstrated varying insurance coverage including rural insurance, employee medical insurance, social insurance, and major illness coverage. Family structures showed diverse patterns, encompassing participants living independently, with spouses, with children, or in multi-generational households. Primary caregiving arrangements similarly reflected this diversity, with care provided by spouses, children, or combinations thereof, ensuring broad representation of elder care dynamics (Table 1). Inclusion criteria comprised age ≥ 60 years, cognitive capability to comprehend research instruments, and willingness to provide informed consent. Exclusion criteria encompassed moderate to severe cognitive impairment or psychological disorders [20], acute medical conditions, and unwillingness to participate. Theoretical saturation was achieved when no new properties emerged in the theoretical categories during the final three interviews [16, 21].

Table 1.

Participant demographic characteristics

Stage	Number	Age Range	Insurance Type	Number of Children	Living with Children	Spouse Alive	Primary Caregiver
Pre-experiment Stage	P1	61–65	Employee Medical Insurance	1	Yes	No	Self or Children
	P2	76–80	Social Insurance	1	Yes	Yes	Self or Spouse
	P3	91–95	Rural Insurance	3	No	No	Children or Children’s Spouse
Stage 1	P1	61–65	Rural Insurance	3	No	Yes	Spouse
	P2	71–75	Rural Insurance	2	No	Yes	Spouse
	P3	56–60	Employee Medical Insurance	2	Yes	Yes	Spouse
	P4	76–80	Rural Insurance	3	Yes	Yes	Self
	P5	76–80	Major Illness Insurance	2	No	Yes	Spouse
	P6	61–65	Rural Insurance	2	Yes	No	Children
	P7	91–95	Employee Medical Insurance	1	No	No	Children or Neighbors
	P8	61–65	Major Illness Insurance	1	Yes	Yes	Spouse or Children
	P9	71–75	Social Insurance	1	No	Yes	Spouse
	P10	81–85	Social Insurance	2	Yes	No	Children or Children’s Spouse
	P11	76–80	Rural Insurance	4	Yes	No	Children
	P12	66–70	Rural insurance	1	No	Yes	Children or Children’s Spouse
Stage 2	P1	81–85	Rural insurance	5	Yes	No	Children
	P2	66–70	Civil servant medical insurance	1	No	Yes	Spouse
	P3	61–65	Rural insurance	1	Yes	Yes	Spouse
	P4	61–65	Rural insurance	1	No	Yes	Spouse
	P5	61–65	Full public expense coverage	1	No	No	Children
	P6	61–65	Rural insurance	2	Yes	Yes	Spouse
	P7	66–70	Rural insurance	2	Yes	Yes	Self
	P8	56–60	Social insurance	1	Yes	Yes	Spouse
	P9	61–65	Major illness insurance	1	Yes	Yes	Spouse
	P10	56–60	Social insurance	1	Yes	Yes	Spouse
	P11	66–70	Employee medical insurance + Major illness insurance	1	Yes	Yes	Spouse or Caregiver
	P12	81–85	Employee medical insurance	2	No	Yes	Spouse
	P13	71–75	Social insurance	2	Yes	No	Children

The study included 13 males and 12 females. Individual participant information has been anonymized to protect confidentiality while maintaining demographic representativeness.

Data collection

The interview guide development followed an iterative process, with the preliminary outline undergoing refinement through pre-interview. Version 1.0 (Supplement File 1) incorporated five primary domains derived from our previous questionnaire survey findings and literature review: attitudes toward illness and death, cognition and knowledge, health insurance and economic considerations, family dynamics and decision-making processes, and needs assessment. The data collection process is illustrated in Fig. 2.

Fig. 2.

Flowchart of data collection

The interview process evolved through two distinct stages, with initial interviews involving twelve participants (mean duration: 52 min) informing subsequent protocol refinements. Analysis of Stage 1 data revealed theoretical gaps regarding socioeconomic influences, family decision-making structures, and healthcare system interactions that necessitated more targeted inquiry. Consequently, the Stage 2 interview guide incorporated additional probes exploring participants’ insurance experiences, family communication patterns, and decision-making hierarchies to elucidate conditional relationships between these factors and advance care planning perspectives. This theoretical sampling approach deliberately recruited thirteen participants with varied socioeconomic backgrounds and insurance coverage models to achieve saturation of emergent constructs related to how cultural values, family composition, and economic considerations influence advance care planning engagement.

All interviews were conducted in private settings, audio-recorded with consent, and supplemented with field notes to capture contextual information and non-verbal communications.

Data analysis

Analysis proceeded concurrently with data collection, adhering to constructivist grounded theory principles [16, 17]. Initial coding involved line-by-line analysis to identify salient actions, meanings, and concerns. Following Charmaz’s (2006) recommendations, focused coding aggregated significant codes based on conceptual relationships, yielding preliminary subcategories. Axial coding examined the properties and dimensions of these subcategories.

NVivo 12 software facilitated data management and hierarchical code organization throughout this iterative process. The analysis was conducted by a multidisciplinary team with expertise in qualitative methods, geriatric care, and Chinese medical ethics, utilizing Edwards-Jones’s NVivo guidelines [22] for systematic data management.

Chinese medical ethical concepts informed the interpretive framework, drawing particularly on Nie’s (2013) principles of ren (benevolence), li (propriety), and xiao (filial piety), and he (harmony). This ethical lens guided our analysis of family-centered decision-making patterns, collective harmony considerations, and the integration of traditional values within end-of-life care preferences. This culturally-informed analytical framework guided interpretation while maintaining systematic analytical procedures across multiple levels of abstraction [17].

Rigor and trustworthiness

Multiple strategies were implemented to ensure methodological rigor and establish trustworthiness throughout the research process. Credibility was enhanced through member checking procedures, where verbatim transcripts were returned to participants within two weeks of interviews, allowing for verification of accuracy and clarification of meanings. The research team maintained reflexive journals to document personal assumptions, cultural biases, and interpretive decisions, ensuring transparency in the analytical process given the cultural sensitivity of end-of-life care discussions within Chinese contexts.

Dependability was established through comprehensive documentation of the analytical process. Theoretical memos documented analytical decisions, emergent relationships between categories, and conceptual development throughout all stages of analysis. The constant comparative method guided systematic comparisons within and across cases at each analytical stage, analyzing relationships between data, codes, subcategories, and categories at multiple levels of abstraction [16, 17]. Professional boundaries were established and maintained throughout the research process to ensure methodological integrity.

Confirmability was strengthened through team-based analytical processes involving researchers with expertise in qualitative methods, geriatric care, and Chinese medical ethics. Team members independently coded initial transcripts and subsequently engaged in regular analytical discussions to refine the coding framework. Based on Edwards-Jones’s NVivo guidelines [22], consensus was achieved through collaborative meetings where interpretive discrepancies were addressed by returning to the raw data and examining contextual factors. NVivo 12 software facilitated data management and hierarchical code organization throughout this iterative process.

Transferability was facilitated through theoretical sampling strategies that ensured diverse representation across demographic, socioeconomic as detailed in Table 1. Theoretical saturation was achieved when no new properties emerged in the theoretical categories during the final three interviews [16, 21], demonstrating comprehensive exploration of the phenomenon within the study context.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of Zhejiang Chinese Medical University (approval number: 20250120-1). Participants provided written informed consent. All audio recordings were encrypted and stored securely with password protection, accessible only to authorized research team members. Participant confidentiality was maintained through unique identifier codes, with all data stored following institutional guidelines.

Results

Sample characteristics and data collection

The analysis included data from 25 participants (13 males/12 females) across two stages (12 in stage 1 and 13 in stage 2), following Urquhart’s recommendation on excluding pilot data, excluding 3 participants from pre-experiment stage [23]. Interview duration ranged from 30 to 75 min, with length determined by participant engagement and the complexity of their experiences. Following grounded theory principles that emphasize the depth of meaning construction over temporal duration [17], interviews varied in length based on individual circumstances, communication preferences, and the point at which theoretical saturation was achieved for specific topics. This flexible approach facilitated responsive data collection while ensuring sufficient depth for theoretical development.

Theoretical framework development

To facilitate systematic analysis and maintain participant confidentiality in this multi-stage study, quotations are referenced using stage numbers (Sx), participant identification numbers (Px) and question numbers (Qx). This referencing system enables precise tracking of theoretical constructs across different interview phases and questions, which is essential for grounded theory analysis.

The substantive theory derived from the analysis is “Navigating the Path to Planned Endings”. This core category emerges from three interconnected main categories: Negotiating Death Discourse, The Locus of Decision, and Systemic Support Infrastructure. Figure 3 demonstrates the theoretical framework through hierarchical relationships where three main categories (dark gray sections) exhibit bidirectional causal relationships with “The Locus of Decision” as the central ethical phenomenon. The diagram illustrates conditional relationships where advance care planning decisions emerge through the moderating effects of mortality discourse negotiation, family influence patterns, and systemic support availability, with feedback loops indicating iterative processes between categories.

Fig. 3.

Navigating the Path to Planned Endings

“The Locus of Decision” functions as the core ethical category where participants reconcile individual autonomy, filial obligations, and family harmony. This central phenomenon encompasses the dynamic interaction among moral agency, cultural values, and medical decision-making through simultaneous consideration of personal preferences, family welfare, and cultural appropriateness. The theoretical relationships demonstrate consequential conditions where Negotiating Death Discourse creates the contextual foundation for decision-making processes, while Systemic Support Infrastructure provides intervening conditions that either facilitate or constrain ethical resolution. Participants resolve ethical conflicts through culturally informed strategies involving iterative family communication processes that build consensus while preserving individual dignity and maintaining collective harmony, representing feedback mechanisms that reinforce traditional Chinese ethical frameworks.

The analysis identified ethical tensions between individual autonomy and collective family decision-making across all participant groups. Participants reported moral conflicts when personal end-of-life preferences diverged from family expectations, particularly regarding life-sustaining treatments and care location preferences. The data revealed conflicts between filial obligations (Xiao) and individual agency assertion, where adult children experienced tension between respecting parental authority and expressing personal healthcare preferences.

Participants described resolution strategies that prioritized relational harmony (He) and collective welfare over individual choice through indirect communication patterns and consensus-building processes. The findings demonstrate that ethical decision-making involved moral compromises integrating traditional Chinese principles with medical requirements, where participants employed culturally informed negotiation processes to address competing moral obligations while maintaining family unity.

The analysis revealed how these categories elucidate ACP engagement among elderly Chinese participants. Negotiating Death Discourse encompasses culturally mediated approaches to mortality conversations through indirect communication patterns that reflect Li (propriety) in appropriate death-related discourse. The Locus of Decision highlights the balance between personal autonomy and family influence in medical decision-making, shaped by Xiao (filial piety) and He (harmony) as intervening conditions that moderate individual agency expression. The Systemic Support Infrastructure category identified variation in ACP understanding and implementation needs as contextual conditions, while revealing socioeconomic constraints as structural conditions affecting healthcare decisions through their impact on Ren (benevolence) expression in care provision. Detailed themes, subthemes, and nodes are presented in Supplement File 3.

Discussion

LNavigating the path to planned endings: a novel framework for understanding ethical decision-making in Chinese ACP context

This grounded theory study produced a substantive theoretical framework titled “Navigating the Path to Planned Endings” that explicates the complex ethical processes through which Chinese older adults engage with advance care planning. The framework encompasses three key interrelated categories - Facing End-of-Life Realities, the Locus of Decision, and Systemic Support Infrastructure - with the Locus of Decision as the core theoretical category representing the central moral phenomenon around which other aspects of the ACP experience revolve.

The theoretical significance of “the Locus of Decision” as the core category reflects fundamental characteristics of Chinese cultural contexts, where healthcare decision-making is intrinsically embedded within familial and social relationships [24]. While bioethical principles emphasize respect for individual autonomy, Collectivist Decision-Making Theory [25] illuminates how moral agency manifests differently in Chinese society through prioritization of group harmony over individual preferences. Family Systems Theory [26] explains how interconnected family relationships create recursive patterns of influence in healthcare decisions, particularly evident in Chinese families where multiple generations often cohabitate and share moral responsibility for medical choices. Unlike Western family involvement that operates as consultative support within an autonomy-centered framework, Chinese family engagement represents moral obligation and hierarchical authority embedded within collective decision-making structures.

Nie’s (2013) analysis of Chinese medical ethics reveals how ren (benevolence), li (propriety), xiao (filial piety), and he (harmony) create institutionalized patterns of shared moral authority that transcend individual patient preferences. Our findings demonstrate this distinction through participants’ expressions of filial guidance acceptance, where statements such as “I think for things like this, I should consider my son’s opinion” (S1, Q4, P6) and “When we get older, such important decisions should be made by our children” (S1, Q10, P9) reflect not merely consultation but moral transfer of decision-making authority based on intergenerational obligations. This theoretical centrality diverges fundamentally from Western ACP frameworks that privilege individual autonomy [27]. The framework captures how traditional Confucian values create a fundamentally different moral landscape for advance care planning, where decision-making authority flows through relational networks rather than residing within individual agents. Empirical evidence illustrates these dynamics through participants’ navigation of competing moral claims, as demonstrated in expressions like “Independence is important, but maintaining family peace and collective well-being is equally important - I must balance both” (S1, Q8, P4), revealing the complex moral calculus that distinguishes Chinese ACP engagement from Western individualistic approaches. These cultural dynamics operate through specific mechanisms including family-mediated communication patterns, intergenerational power dynamics, and shared responsibility for end-of-life decisions [28]. This understanding challenges Western bioethical assumptions about moral agency and suggests that effective ACP implementation must reconceptualize autonomy as relational rather than individual.

The category Facing End-of-Life Realities expands current understanding of moral approaches to death and end-of-life experiences in Chinese culture. Terror Management Theory [29] provides insight into how Chinese cultural beliefs about death and ancestral worship serve as anxiety-buffering mechanisms, influencing how older adults approach the ethical dimensions of end-of-life planning. Our findings reveal culturally specific manifestations within Chinese contexts that fundamentally shape ACP engagement patterns through participants’ expressions of cultural taboos and superstitious beliefs, as evidenced by statements such as “In our culture, we don’t discuss these things openly - it’s considered bad luck” (S1, Q4, P1) and “Traditional values teach us to avoid discussing death and illness when we’re healthy” (S2, Q8, P13). These findings reveal how Chinese cultural death anxiety operates through collective rather than individual psychological mechanisms, where concerns about discussing mortality stem from beliefs about inviting misfortune upon the family unit. The empirical data demonstrates how li (propriety) governs culturally appropriate approaches to mortality discourse, creating indirect communication patterns that reflect efforts to maintain he (harmony) while addressing end-of-life planning needs. Healthcare providers’ ethical obligations to provide culturally competent care necessitate understanding how Chinese older adults approach ACP in ways that both reflect and extend beyond traditional “good death” conceptualizations in Chinese contexts [7].

Our findings demonstrate how dignity in Chinese contexts operates through collective rather than individual constructs, as participants expressed concerns about maintaining family dignity through statements like “We shouldn’t talk about death directly, but the family understands what I mean - it’s about maintaining face and proper conduct even at the end” (S1, Q3, P1). This perspective reveals how ren (benevolence) manifests through protecting family members from emotional distress while preserving collective honor, reflecting how Chinese cultural expectations about filial care and family presence shape ethical preferences at life’s end.

The Systemic Support Infrastructure category reveals how institutional and structural factors distinctively affect the ethical implementation of ACP in Chinese healthcare settings. Social Determinants of Health Theory [30] highlights the moral imperative to advocate for equitable access to ACP resources within China’s rapid healthcare system transformation and urban-rural disparities. Participants’ experiences reveal how financial limitations affect moral decision-making through statements such as “If treating my illness bankrupts my child, I couldn’t live with myself as a mother” (S1, Q7, P7), illustrating how ren (benevolence) manifests through parental concern for children’s welfare. These findings demonstrate how economic considerations become morally charged within Chinese family systems, where traditional obligations of xiao (filial piety) intersect with practical resource limitations to create complex ethical dilemmas.

Educational disparities create differentiated patterns of moral agency, as evidenced by participants’ statements like “People like us without education. have to ask our children about everything” (S1, Q5, P6), demonstrating how li (propriety) establishes hierarchical expectations for knowledge acquisition and decision-making authority. Ethical frameworks examining China’s hierarchical healthcare structure and traditional doctor-patient relationships demonstrate how these factors influence moral decision-making in ACP discussions, while Health Communication Models [31] illuminate the unique challenges of facilitating ethically sound end-of-life conversations within Chinese cultural norms of indirect communication about death [32]. Successful ACP implementation requires systemic interventions that address structural inequities while simultaneously supporting culturally appropriate communication patterns.

“Navigating the Path to Planned Endings” advances understanding of ethical decision-making in Chinese ACP implementation by offering a more nuanced and integrated perspective than previous models. While existing frameworks often examine cultural factors, family dynamics, or systemic barriers in isolation, this theoretical framework reveals their intricate interdependence in shaping moral choices, with the Locus of Decision as the core phenomenon around which personal beliefs, family relationships, and healthcare systems converge. The framework’s theoretical innovation lies in demonstrating how ethical decision-making in Chinese contexts operates through multiple simultaneous levels of moral consideration, requiring healthcare interventions that address individual, familial, and systemic dimensions concurrently. This integrated approach offers a theoretical basis for developing culturally appropriate interventions that acknowledge and address the multiple levels of moral influence shaping end-of-life care planning in Chinese society.

Unpacking the decision-making journey: analysis of seven axial categories shaping ACP in Chinese healthcare

The theoretical framework “Navigating the Path to Planned Endings” illuminates how three key categories shape the moral dimensions of advance care planning in the Chinese healthcare context. These categories - Facing End-of-Life Realities, Decision-Making Dynamics, and Systemic Support Infrastructure - converge around the core category “The Locus of Decision,” with seven axial coding categories further elaborating their ethical dimensions.

The empirical analysis reveals how Confronting Mortality and Evaluating Life Support operate as interconnected processes within Facing End-of-Life Realities, where participants consistently expressed concerns about maintaining dignity while avoiding prolonged suffering that would burden family members. This integration reflects how li (propriety) governs culturally appropriate approaches to discussing death while ren (benevolence) motivates concern for family welfare. Contemporary bioethics emphasizes the fundamental obligation to support patients through this complex journey of mortality acceptance and evaluation of life-sustaining treatments [33]. These perspectives present crucial ethical considerations for healthcare providers facilitating end-of-life discussions, particularly regarding moral approaches to aggressive medical treatments within Chinese cultural contexts, where traditional Confucian values and cultural taboos around death significantly influence moral approaches to end-of-life planning [34].

Facing End-of-Life Realities influences both Systemic Support Infrastructure and The Locus of Decision unidirectionally, fundamentally shaping how individuals engage with the ethical dimensions of advance care planning. Our findings demonstrate this relationship through participants’ expressions of how mortality awareness facilitated understanding of ACP’s alignment with their values regarding dignity maintenance and family welfare consideration. Terror Management Theory [29] explains how cultural worldviews about death create specific patterns of healthcare system engagement, where acceptance of mortality facilitates active information seeking while death anxiety promotes delegation of decision-making authority. Understanding this relationship proves crucial as theoretical frameworks suggest that greater acceptance of mortality typically correlates with increased moral agency in healthcare engagement and decision-making autonomy [35]. Conversely, death-related anxieties or concerns about burdening others often correlate with preferences for delegating moral authority [36]. This dynamic presents fundamental ethical challenges in balancing respect for individual autonomy with family-centered moral traditions.

The axial categories within Decision-Making Dynamics—Deference to Medical Authority, Filial Guidance Acceptance, and Individual Agency Assertion—operate through competing moral frameworks that create tension within The Locus of Decision. Participants’ navigation between these orientations reveals the complexity of Chinese medical decision-making, where individuals expressed simultaneous desires for personal autonomy and concerns about maintaining family harmony through considerate decision-making. The Locus of Decision as the core category captures the ethical relationship between Decision-Making Dynamics and Family Sway in Chinese elderly individuals’ engagement with advance care planning. Healthcare providers face complex moral considerations when medical information disclosure and end-of-life care decisions are heavily influenced by filial piety consciousness, as the ethical dynamics often shift toward family control, particularly by adult children [37].

The empirical data reveals how Family Sway operates through three interconnected subcategories—Emotional Bonds and Filial Piety, Intergenerational Care Obligations, and Harmony Preservation and Consensus Building—that collectively shape decision-making authority distribution. Participants consistently emphasized the importance of involving all family members in important decisions to ensure collective agreement and maintain relational unity, demonstrating how he (harmony) functions as both a guiding principle and practical constraint in ethical decision-making. This family sway fundamentally shapes how healthcare choices are morally negotiated and implemented [38], representing the central ethical tension between individual autonomy and familial influence. The moral implications emerge through three distinct orientations: reliance on medical expertise, deference to family, and preference for self-determination [39]. The theoretical impact of family relationships particularly manifests through financial dependencies and moral obligations within Chinese cultural contexts.

The Locus of Decision maintains a dynamic ethical relationship with Systemic Support Infrastructure while being unidirectionally influenced by Facing End-of-Life Realities. This bidirectional relationship operates through feedback mechanisms where individual decision-making preferences influence engagement with support systems, while systemic barriers simultaneously constrain available choices. Participants’ experiences illustrate this dynamic through expressions of how limited insurance reimbursement affects treatment decisions and how improved coverage would expand their willingness to pursue medical interventions, demonstrating how economic constraints reshape moral decision-making priorities. This relationship highlights the moral responsibility to facilitate informed decision-making, as enhanced systemic support enables individuals to better articulate and implement their ethical preferences [40]. The ethical principle of beneficence manifests when theoretical frameworks examining acceptance of death’s inevitability [41] suggest correlations with more definitive moral stances on end-of-life decision-making.

The three axial categories comprising Systemic Support Infrastructure—Grasping the Concept, Seeking Implementation Support, and Socio-Economic Constraints—operate through intersecting mechanisms that create differential access to ACP resources. The empirical evidence demonstrates how these categories interact to shape moral agency, as participants with limited educational backgrounds consistently expressed dependence on their children’s knowledge and judgment for complex medical decisions. This pattern reveals how educational disparities intersect with cultural values to create stratified patterns of moral authority within families. The moral obligation to promote health equity becomes evident through theoretical analysis of varied experiences with healthcare systems, ranging from conceptual understanding to practical constraints. The socioeconomic dimension particularly affects ethical engagement with support systems [42]. These disparities present moral challenges in advocating for equitable access to ACP resources. Educational background also emerged as a crucial factor in ethical decision-making [43], with theoretical frameworks suggesting that higher education correlates with greater understanding and acceptance of advance care planning concepts.

The mediating role of Systemic Support Infrastructure between mortality attitudes and decision-making outcomes operates through selective filtering mechanisms, where institutional barriers create differential access to information and implementation support based on socioeconomic position. Participants’ varied responses to ACP concepts—ranging from complete unfamiliarity to recognition of meaningful alignment with personal values following explanation—demonstrate how systemic support mediates the translation of individual attitudes into actionable preferences. Systemic Support Infrastructure serves as a critical mediator between traditional moral beliefs about death and ultimate decision-making outcomes [44]. Theoretical perspectives on individual attitudes toward mortality significantly influence how older adults engage with available support systems from an ethical perspective. Theoretical frameworks suggest that more positive orientations toward death typically correlate with greater receptivity to ACP concepts and active pursuit of implementation assistance [45]. This understanding enables healthcare providers to better fulfill their moral obligation to provide patient-centered care, as this relationship manifests in approaches to educational resources and professional guidance, often transcending socioeconomic constraints.

The framework “Navigating the Path to Planned Endings” emerges from this complex interplay between moral beliefs, systemic support, and ethical decision-making processes. This theoretical model illuminates how Chinese elderly individuals navigate end-of-life planning through the dynamic interaction of personal moral orientations, family influences, and healthcare infrastructure, with The Locus of Decision serving as the pivotal mechanism through which these ethical forces converge to shape advance care planning outcomes.

Implications

The “Navigating the Path to Planned Endings” framework reveals critical intervention points requiring systematic healthcare responses that address both individual autonomy and collective family decision-making within Chinese cultural contexts. Clinical implementation demands structured family-mediated shared decision-making protocols that operationalize The Locus of Decision through staged consultation processes [46]. These protocols should incorporate initial individual assessment sessions followed by facilitated family conferences utilizing culturally adapted communication frameworks that respect traditional taboos while ensuring informed consent. Evidence-based models such as the Family-Centered Advance Care Planning (FC-ACP) approach demonstrate effectiveness in collectivist cultures through structured dialogue facilitation that acknowledges hierarchical family dynamics while preserving individual agency [33]. Healthcare providers require specific training in ethical conflict mediation techniques that balance ren (benevolence) and xiao (filial piety) considerations when individual preferences diverge from family expectations. This includes implementing culturally sensitive disclosure strategies that employ indirect communication patterns consistent with li (propriety) while ensuring comprehensive understanding of treatment options and prognosis.

The framework’s identification of systemic barriers necessitates targeted policy interventions addressing educational disparities and socioeconomic constraints that limit moral agency in healthcare decision-making. Healthcare systems should implement tiered ACP education programs tailored to varying literacy levels, utilizing community health workers as cultural intermediaries who can navigate traditional values while promoting contemporary healthcare principles. Insurance reform initiatives must address the identified economic constraints that transform medical decisions into moral dilemmas for families, particularly expanding coverage for palliative care services and long-term care options that align with cultural preferences for family-based caregiving [42]. Policy frameworks should establish standardized ethical consultation services within healthcare institutions, providing structured support for providers navigating complex family dynamics while maintaining professional obligations to patient advocacy.

Healthcare organizations require systematic cultural competency training programs that integrate traditional Chinese medical ethics with contemporary bioethical principles, enabling providers to effectively facilitate ACP discussions within established cultural parameters [47]. These programs should emphasize practical skills in family systems assessment, conflict mediation, and culturally appropriate communication strategies that honor he (harmony) while promoting informed decision-making. Institutional protocols should establish clear guidelines for managing situations where family authority conflicts with individual autonomy, including access to ethics committees trained in cross-cultural healthcare ethics and availability of trained interpreters who understand both linguistic and cultural nuances of end-of-life discussions.

Future research priorities should focus on developing and validating culturally adapted ACP interventions that operationalize the theoretical constructs identified in this study. Intervention studies examining the effectiveness of structured family communication protocols, culturally tailored educational materials, and provider training programs will establish evidence-based approaches to implementing ACP within Chinese healthcare contexts. Longitudinal research examining how cultural values evolve across generations within Chinese families will inform adaptive intervention strategies that remain relevant as societal changes influence traditional healthcare decision-making patterns, while cross-cultural validation studies comparing the framework’s applicability across different Chinese populations, including overseas Chinese communities, will enhance understanding of how cultural assimilation and healthcare system variations affect ACP engagement patterns. Research initiatives should investigate technology-assisted interventions that respect cultural communication preferences while enhancing ACP accessibility, particularly for populations facing geographical or socioeconomic barriers to healthcare access. Studies examining provider perspectives on implementing culturally sensitive ACP protocols will identify institutional facilitators and barriers to systematic adoption of family-centered approaches, while evaluation research focusing on patient and family satisfaction with culturally adapted ACP processes will establish quality metrics that balance respect for traditional values with contemporary healthcare standards, ultimately informing evidence-based guidelines for ethical ACP implementation in Chinese healthcare settings.

Limitations

This study has the following potential limitations: (1) Given China’s ethnic and cultural diversity, the sample size may not fully cover all regional and cultural variations, despite multi-regional sampling efforts. Future studies could explore how the theoretical framework applies across different geographical and cultural contexts within China. (2) While theoretical saturation was achieved, participants were primarily recruited from community settings and nursing homes. The experiences of hospitalized elderly patients facing immediate end-of-life decisions might offer additional insights into the decision-making process and could be explored in future research. (3) The applicability of findings to overseas Chinese communities in culturally diverse societies remains uncertain, as these populations may experience different degrees of cultural assimilation and healthcare system influences that could affect advance care planning perspectives. (4) As a qualitative study employing constructivist grounded theory methodology, the findings reflect subjective interpretations that may be influenced by researcher perspectives, translation considerations, and cultural contexts, despite rigorous analytical procedures employed to minimize such limitations.

Conclusion

This grounded theory investigation reveals the substantive theory “Navigating the Path to Planned Endings” as a comprehensive framework for understanding how Chinese older adults navigate advance care planning within traditional Confucian values and contemporary bioethical principles. The emergence of “The Locus of Decision” as the core theoretical category demonstrates how moral agency operates through dynamic reconciliation of individual autonomy, filial obligations, and family harmony, challenging Western bioethical assumptions about individualistic decision-making. The framework’s three interconnected categories provide crucial insights for developing culturally sensitive ACP implementation strategies that address individual, familial, and systemic dimensions concurrently. Future research should focus on developing and testing culturally adapted ACP interventions based on this theoretical framework, exploring longitudinal changes in decision-making patterns across different stages of aging, and examining the transferability of these findings to other Confucian-influenced healthcare contexts.

Abbreviations

ACP

Advance Care Planning

Author contributions

Wenyu Yue: Conceptualization, Methodology, Software, Formal analysis, Investigation, Data curation, Writing - original draft; Qing Chu: Conceptualization, Investigation, Data curation; Xiaoqin Ma: Conceptualization, Supervision, Project administration, Writing - review & editing.

Funding

This study was supported by (1) 2025 General Projects under the Soft Science Research Program of the Department of Science and Techology of Zhejiang Province (Grant No. 2025C35037); (2) 2025 Zhejiang Chinese Medical University Cultivation Plan for Top Innovative Talents of Postgraduates (No. 2025YJSBJ005).

Data availability

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. We confirm that the dataset used in this manuscript has not been used in any other papers (in progress, under review, or published). There is nothing to declare regarding data overlap.

Declarations

Ethics approval and consent to participate

All procedures involving human participants were conducted in accordance with the Declaration of Helsinki. This study received ethical approval from the Ethics Committee of Zhejiang Chinese Medical University (Approval number: 20250120-1).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Generative AI and AI-assisted technologies in the writing process

During the preparation of this work, the author(s) used ChatGPT by OpenAI to improve the readability and language of the manuscript.