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

Background

Advance care planning (ACP) aligns care with patients’ values and improves end-of-life outcomes. Yet uptake remains limited and frequently crisis-triggered, particularly in collectivist contexts where family interdependence and emotional tolerance shape participation. Empirical understanding of how ACP is experienced across patients, families, and healthcare providers in non-Western settings remains limited.

Objective

To explore how patients, family caregivers, and healthcare providers experience and negotiate participation in ACP within a Thai palliative care context.

Design

Qualitative study using reflexive thematic analysis.

Setting

A university hospital in Bangkok, Thailand.

Participants

Thirty participants: 10 patients with life-limiting illness, 10 family caregivers, and 10 healthcare providers.

Methods

Semi-structured interviews were conducted at a palliative care center between January and October 2025. Interviews were transcribed verbatim, translated using meaning-based equivalence, and analyzed inductively using reflexive thematic analysis.

Results

Four themes (10 subthemes) conceptualized ACP as a relationally negotiated, culturally embedded practice. (1) Timing and pathways: emotional, familial, and structural readiness shaped when ACP became possible, most often during clinical crises. (2) Values and visions of a good death: comfort, peace, and minimizing burden guided preferences, while caregiving and resource constraints limited feasibility. (3) Communication as relational positioning in ACP: gentle honesty and paced disclosure fostered engagement; decisions were negotiated within family circles; physicians typically initiated ACP, while nurses sustained relational continuity. (4) Structural conditions shaping the possibility of ACP: hierarchy, workload, limited training, and constrained community support restricted proactive implementation, reinforcing reactive patterns.

Conclusion

ACP in this context functions as a relationally negotiated practice contingent upon alignment across emotional, familial, and structural readiness. Crisis initiation reflects misalignment across these domains rather than cultural resistance alone. Strengthening culturally attuned communication, family-centered engagement, interdisciplinary role clarity, and structural support may enable earlier and sustained ACP dialogue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-026-02065-5.

Key Message

In collectivist healthcare systems, ACP depends on alignment across emotional, familial, and structural readiness. Without coordinated relational and institutional support, conversations remain crisis-triggered despite shared endorsement of dignified, non-burdensome care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-026-02065-5.

Introduction

Advance Care Planning (ACP) is an ongoing, dynamic process that enables individuals to clarify and communicate their values, goals, and preferences for future medical care in the context of serious illness or declining health [1–6]. Evidence indicates that ACP improves concordance between stated preferences and received care, reduces unwanted life-sustaining treatment, and enhances family satisfaction with end-of-life care [4–6]. Despite these benefits, global uptake remains inconsistent and frequently occurs late in the illness trajectory [4, 7–9].

ACP typically involves assessing multiple forms of readiness: the patient’s emotional and cognitive preparedness to engage in discussion, the family’s willingness to participate in shared decision-making, and clinicians’ judgement regarding clinical appropriateness and timing across the illness course [3]. In practice, readiness is not solely an individual psychological state but operates relationally and structurally, shaped by interpersonal dynamics, communication norms, and health system conditions. Delays in initiation have been associated with prognostic uncertainty, fear of diminishing hope, and discomfort with discussing decline [7, 10]. This study conceptualizes readiness not as an individual attribute but as a multi-level, relational condition encompassing emotional, familial, and structural dimensions that shape how ACP participation unfolds.

Over the past decade, ACP has evolved from a document-centered intervention toward a person-centered communication process grounded in trust, relational continuity, and iterative dialogue [7, 11–13]. Patients often describe ACP as both reassuring and confronting, reflecting tension between preparation and preservation of hope [7]. Families may prioritize emotional protection and harmony, while clinicians emphasize clinical clarity and professional responsibility [11, 13]. Nurses frequently play a facilitative role due to their relational proximity and continuity with patients [11].

This shift aligns with relational autonomy theory, which conceptualizes decision-making as embedded within interpersonal relationships and institutional contexts rather than solely within individual self-determination [14–16]. Autonomy is negotiated and context-sensitive, particularly in serious illness where interdependence intensifies. Such perspectives suggest that ACP participation emerges through interaction among patients, families, and clinicians rather than unilateral decision-making.

However, much of the empirical evidence informing ACP implementation originates from North American, European, and Australian health systems, where individual autonomy and direct disclosure are normative [4, 7] In contrast, studies from East and Southeast Asian contexts, including Japan, Taiwan, and Singapore, suggest that ACP discussions are often initiated later in illness trajectories, mediated through family hierarchies, and shaped by cultural norms favoring indirect communication and emotional protection [17–20]. In these settings, decision-making is frequently relational rather than individually declared, with spiritual beliefs and collective moral responsibility influencing interpretations of a good death, particularly ideals of harmony, non-burden, and protection of loved ones [12, 20]. While this body of work has identified culturally specific barriers and facilitators to ACP engagement, it has largely examined stakeholder perspectives separately and has paid limited attention to how participation is negotiated in real-time clinical encounters among patients, families, and healthcare providers.

Thailand reflects many of these relational and structural dynamics. The National Health Act B.E. 2550 legally affirms individuals’ rights to refuse life-sustaining treatment, establishing a supportive framework for ACP [21]. Subsequent national guidelines have endorsed policy-level integration. Nevertheless, implementation in routine practice remains uneven. Specialist palliative care services are concentrated primarily within tertiary referral hospitals, where ACP discussions are commonly initiated by physicians following advanced illness referral and supported by interdisciplinary teams, including nurses who sustain relational dialogue [22]. Outside these centers, structured ACP processes and documentation remain limited and inconsistently integrated into routine care pathways. Structural constraints, including workforce workload, limited experiential communication training, hierarchical practice patterns, and fragmented community services, may further delay early and proactive initiation [8, 22].

Within Thai cultural contexts, strong family interdependence, Buddhist perspectives on acceptance of impermanence, and respect for medical authority shape end-of-life communication practices [20]. Decision-making is often relationally embedded, with families playing an active role in mediating information and protecting emotional equilibrium. These dynamics do not preclude ACP engagement; rather, they influence how readiness is recognized, who assumes responsibility for initiating discussion, and how preferences are negotiated within family networks. Understanding ACP in this setting therefore requires attention to relational processes alongside structural conditions that enable or constrain participation. Although legal rights to refuse life-sustaining treatment are formally established, routine integration of ACP into early-stage illness discussions remains variable and context-dependent.

Prior studies in Thailand and internationally have largely examined ACP experiences from the perspective of single stakeholder groups, patients, family caregivers, or clinicians, separately [7, 13, 23]. While such work has identified factors such as emotional preparedness, communication competence, and organizational capacity, it has offered limited insight into how these dimensions interact during shared clinical encounters. In practice, ACP discussions unfold through the simultaneous negotiation of emotional, familial, and structural readiness across interacting parties. An integrated triadic perspective is therefore necessary to understand how timing, communication, and institutional conditions converge to shape participation.

While ACP is legally authorized at the national level, integration into routine, early-stage illness discussions remain institutionally concentrated rather than system-wide. To advance ACP implementation globally, it is essential to examine how emotional, familial, and structural readiness interact in settings where palliative care resources are developing and where multi-party collaboration is required for decision-making. This study offers an empirically grounded articulation of readiness as a relational, multi-level condition shaping ACP participation within a Thai palliative care context. Accordingly, this study aimed to explore how patients, family caregivers, and healthcare providers experience participation in ACP discussions in a tertiary palliative care setting in Thailand.

Methods

Research aim

This study aimed to explore how patients, family caregivers, and healthcare providers experience participation in ACP within the Thai palliative care context.

Study design

This study employed reflexive thematic analysis (RTA) as articulated by Braun and Clarke [24–26]. The study was informed by a contextualist critical realist paradigm, recognizing that experiences of ACP are shaped by real structural conditions (e.g., institutional hierarchies, resource constraints) while also socially constructed through cultural norms, relational dynamics, and communication practices.

RTA was selected for its suitability in generating interpretative accounts of patterned meaning across diverse perspectives while foregrounding researcher reflexivity as integral to knowledge production. This approach aligns with the study’s aim to understand how ACP experiences are constructed and negotiated within the Thai palliative care context.

Setting, sample, and participants

This study was conducted at the Palliative Care Center of a large university hospital in Bangkok, Thailand, a national tertiary referral hub where formal ACP consultations are routinely conducted. In Thailand, although ACP is legally supported, implementation remains concentrated in tertiary settings, making this site an information-rich context for examining ACP practice.

Participants were recruited using purposive and snowball sampling [27]. Eligible individuals were aged ≥ 18 years and included: (1) patients with life-limiting illness who had previously participated in formal ACP consultations; (2) family caregivers involved in those discussions; and (3) healthcare providers with at least six months of ACP facilitation experience within the service. Family caregivers were defined as relatives actively involved in care decisions or daily caregiving responsibilities.

Patients and family caregivers were recruited independently; although some represented patient–family pairs, participation was not restricted to matched dyads. Healthcare providers were not required to have facilitated ACP for specific participating patients but were recruited based on broader service experience.

Eligible patients had decision-making capacity and awareness of their diagnosis, as routinely assessed by the palliative care team prior to referral. Prior ACP participation was confirmed through clinical documentation and team verification. ACP in this study referred to structured discussions within the palliative care service addressing goals of care, treatment preferences, or advance directives. Healthcare providers’ facilitation experience was confirmed through role description and service records.

Potential participants were identified by palliative care staff and initially approached during clinical visits. Study information was provided by clinical staff, and interested individuals were contacted by the principal investigator to arrange interviews. Written informed consent was obtained prior to participation. No invited participants declined.

A target of 24 participants (eight per group) was set based on information power principles [28], considering sample specificity, study aim, and anticipated dialogue quality. Recruitment continued until sufficient depth and diversity were achieved to support coherent interpretation.

Data collection

A semi-structured interview guide was developed from existing literature [11, 23] (Supplementary Material 1), refined through three rounds of expert review by two external qualitative and ACP specialists, and piloted with one participant per group for clarity and contextual fit.

Following informed consent, face-to-face interviews in private site rooms ensured confidentiality. Individual format minimizes clinical power imbalances. Interviews in Thai were conducted by the principal investigator (female, PhD with ACP and qualitative expertise), supported by palliative care team members.

Interviews (audio-recorded verbatim; mean 52 min, range 38–65) generated rich data. Field notes captured contextual observations/preliminary insights. Transcripts were produced verbatim in Thai within 24 h.

Transcripts were initially coded in Thai, then translated thematically into English by bilingual experts using meaning-based equivalence to preserve cultural nuance (e.g., relational terms) [29]. Bilingual verification ensured fidelity across languages. Member reflections (not validation) were sought selectively from healthcare providers; vulnerable patients/families were not recontacted to minimize burden/distress [25].

Data analysis

Data were analyzed inductively using reflexive thematic analysis within a contextualist critical realist paradigm, following Braun and Clarke’s six-phase approach [24]. Field notes were integrated following transcript verification and anonymization.

Interviews were conducted and transcribed in Thai. Initial coding and theme development occurred in Thai to preserve semantic and cultural nuance. Translation into English took place during later analytic phases and prioritized conceptual equivalence over literal correspondence [29]. Translation decisions were discussed among bilingual team members to maintain interpretive coherence. We recognize translation as an interpretive act that may shape analytic emphasis.

Analysis involved iterative familiarization, flexible coding of semantic and latent meanings relevant to the research question, and the development of themes as coherent patterns of shared and divergent meaning across participant groups. Analytic discussions with team members were used to deepen reflexive engagement and explore alternative interpretations rather than to achieve consensus or reliability.

Quality and transparency were guided by Braun and Clarke’s Reflexive Thematic Analysis Reporting Guidelines (RTARG) [26] and their values-based reporting framework [30], with emphasis on methodological coherence, reflexive transparency, and clear articulation of interpretive decisions.

The first author, a nurse researcher with expertise in ACP and no prior clinical relationship with participants, maintained a reflexive journal throughout analysis. The research team’s clinical backgrounds and familiarity with Thai healthcare hierarchies were acknowledged as shaping interpretation, and ongoing dialogue supported critical examination of analytic positioning.

Ethical considerations

Ethical approval was obtained from the Mahidol University Multi-Faculty Cooperative Institutional Review Board (MU-MOU-IRB-NS2024/76.2910, , Certificate of Approval No. IRB-NS2025/907.1001). Written and verbally informed consent was obtained from all participants before data collection. Participation was voluntary, and confidentiality was maintained through the pseudonymization of transcripts and secure, password-protected data storage accessible only to the research team. The audio recordings were deleted immediately after the transcription verification. Participants were informed of their right to withdraw at any stage without consequence.

Results

Participant characteristics

Thirty participants were included: 10 patients, 10 family caregivers, and 10 healthcare providers. Overall, 21 of 30 participants were female (70%). Patients had a mean age of 63 years (range 35–78) and all had a cancer diagnosis, most commonly lung cancer (n = 4/10), hepatocellular carcinoma (n = 3/10), and gynecologic cancer (n = 2/10). Family caregivers had a mean age of 49 years (range 27–72) and were most commonly adult children (n = 4/10) or grandchildren (n = 3/10); caregiving experience varied, with most reporting ≤ 5 years (n = 9/10). Healthcare providers had a mean age of 41 years (range 25–50) and a mean of 14 years of clinical experience (range 2–28); the sample included nurses (n = 6/10), family medicine physicians (n = 3/10), and one allied health practitioner in Traditional Thai medicine (n = 1/10). Healthcare providers were recruited from the Palliative Care Centre and affiliated clinical services; some had specialist palliative care roles, while others collaborated with the palliative team and had experience supporting ACP facilitation. Detailed participant characteristics are presented in Table 1.

Table 1.

Characteristics of participants (N = 30)

Characteristic	Patients (n = 10)	Family Caregivers (n = 10)	Healthcare Providers (n = 10)
Sex
Female	4 (40)	8 (80)	9 (90)
Male	6 (60)	2 (20)	1 (10)
Age (years)	Mean 63 (35–78)	Mean 49 (27–72)	Mean 41 (25–50)
Primary diagnosis (patients)
Lung cancer	4 (40)	-	-
Hepatocellular carcinoma (HCC)	3 (30)	-	-
Gynecologic cancer	2 (20)	-	-
Bladder cancer	1 (10)	-	-
Role / Relationship
Spouse	–	2 (20)	–
Child	–	4 (40)	–
Grandchild	–	3 (30)	–
Parent	–	1 (10)	–
Profession	–	–
Nurse	–	–	6 (60)
Physician (family medicine)	–	–	3 (30)
Allied health (Traditional Thai medicine)	–	–	1 (10)
Caregiving experience (years)	–		–
≤1 year	–	3 (30)	–
2–3 years	–	3 (30)	–
4–5 years	–	3 (30)	–
≥10 years	–	1 (10)	–
Clinical experience (years)	–	–	Mean 14 (2–28)
Family structure
Nuclear	6 (60)	4 (40)	–
Extended	4 (40)	6 (60)	–

Reflexive thematic analysis

The analysis identified four main themes describing participants’ experiences of ACP. Table 2 summarizes the themes and subthemes, which are presented below with illustrative quotations. To support interpretation of excerpts, quotations are labelled by participant group (P = patient, F = family caregiver, H = healthcare provider). Across themes, participants’ accounts reflected interconnected dimensions of emotional, familial, and structural readiness shaping when and how ACP participation unfolded.

Table 2.

Themes and subthemes describing experiences of advance care planning

Theme	Subtheme
1: Timing and Pathways into ACP	1.1 Readiness and Preferred Timing of ACP
	1.2 Crisis-Triggered Entry
	1.3 Everyday Care as a Natural Entry Point
2: Values and Visions of a Good Death	2.1 Peace, Comfort, and Non-Burden as Relational Obligations
	2.2 Place of Care, Safety, and Family Harmony
	2.3 Life Completion, Rituals, and Preparation Actions
3: Communication and Relational Positioning in ACP	3.1 Tone, Framing, and the Emotional Pace Disclosure
	3.2 Responsibility, Authority, and Interdisciplinary Roles in Initiating ACP
4: Structural Conditions Shaping the Possibility of ACP	4.1 Economic and Resource Limits Shaping ACP Decisions
	4.2 Limited Preparation and Hesitant Initiation
	4.3 – Hierarchy and Workload Reinforce Reactive ACP

Theme 1: timing and pathways into ACP

This theme captures how ACP conversations became possible through the alignment, or misalignment, of multiple conditions rather than through chronological timing alone. Although participants often framed ACP in terms of early or late discussions, initiation was shaped by the interaction of patients’ emotional readiness, families’ willingness to engage, clinicians’ assessment of disease trajectory, and the relational context in which conversations unfolded. ACP therefore emerged not simply as a function of illness stage, but as a negotiated moment in which emotional, familial, and service-level conditions converged sufficiently to make discussion feasible. When such alignment was absent, conversations were commonly delayed until deterioration or crisis compelled initiation.

Participants generally believed ACP should begin while patients remained able to express their wishes. However, in practice, discussions were often postponed until illness worsened or relational trust had been established.

Subtheme 1.1 readiness and preferred timing of ACP

This subtheme reflects how ACP initiation was shaped by perceived readiness at multiple levels. Readiness referred primarily to patients’ emotional preparedness and family caregivers’ willingness to engage, while healthcare providers calibrated timing based on clinical trajectory and relational trust. Preferred timing therefore varied across participants and referred to the point in the illness trajectory when ACP felt acceptable, manageable, or appropriate.

Many patients expressed a preference for early discussions while they were still able to articulate their wishes. P9 explained, “We should talk once we know the diagnosis, so we can prepare our minds.” Early discussion was described as enabling psychological preparation and future planning.

Yet emotional readiness was uneven. Some participants described reluctance to confront decline. P7 shared, “I don’t want to talk about getting worse yet, it makes me stressed.” In such cases, ACP was perceived as overwhelming rather than supportive. Healthcare providers described carefully balancing clinical timing and emotional capacity: ACP should occur “not so late that the chance is gone, but not so early that the patient is still in shock” (H7), and “once trust has settled, not before” (H8). These accounts suggest that initiation required not only clinical appropriateness but relational stability and emotional tolerance.

Subtheme 1.2 crisis-triggered entry

In contrast to the ideal of early and gradual planning, many participants described encountering ACP reactively during episodes of acute deterioration. Rather than unfolding as reflective, future-oriented discussion, ACP was often introduced under clinical pressure when urgent decisions about life-sustaining treatment were required.

P4 recalled, “I first heard about it in the emergency room when the doctor asked if I wanted CPR,” illustrating how ACP became framed narrowly around immediate intervention rather than broader goals of care. Similarly, F2 observed, “We usually begin ACP during crisis.” Healthcare providers acknowledged this pattern; as H5 explained, “We start ACP only when the case is referred as nothing more can be done.”

In these circumstances, ACP functioned less as anticipatory planning and more as a response to impending loss of decision-making capacity. Crisis appeared to compress emotional hesitation and structural delay, creating urgency that compelled conversation even when earlier opportunities had been deferred.

Subtheme 1.3 everyday care as a relational entry point

Distinct from readiness defined solely by disease trajectory, this subtheme highlights how ACP became possible through the relational context of everyday care. Participants described ACP as more approachable when introduced gradually within routine clinical interactions rather than as a formal, scheduled meeting. In these situations, readiness emerged through familiarity, trust, and the ordinariness of care encounters.

Some patients felt most comfortable discussing ACP within the rhythm of daily care rather than in conference rooms or intensive care settings. P3 reflected, “The nurse’s gentle care made it easier to talk about dying.” Healthcare providers similarly described integrating discussions into routine activities: “We talk during wound care or IV time; it flows naturally” (H4).

These accounts suggest that everyday clinical relationships function as conversational infrastructure. Through repeated, low-pressure interactions, difficult topics could surface incrementally, allowing ACP to unfold without the abruptness often associated with crisis or formal consultation.

Theme 2 values and visions of a good death

This theme captures how participants’ understandings of a “good death” shaped not only their end-of-life preferences but also their willingness to engage in ACP conversations. Rather than approaching ACP as a purely clinical planning exercise, participants interpreted it through relational, ethical, and cultural values. These values influenced what was prioritized, how decisions were framed, and when conversations felt appropriate. In this way, ACP participation was embedded within moral responsibility, family harmony, and spiritual meaning.

Across participant groups, a good death was associated with comfort, emotional calm, and minimizing burden to loved ones. These priorities did not simply guide treatment preferences; they shaped the emotional tone, boundaries, and pace of ACP discussions.

Subtheme 2.1 peace, comfort, and non-burden as relational obligations

Across participant groups, decisions about limiting aggressive treatment were framed not only as clinical preferences but as expressions of relational responsibility. Avoiding prolongation was described as ethically appropriate conduct within family relationships, particularly to prevent emotional and practical burden for loved ones.

Patients frequently positioned comfort as an act of protection. P2 stated, “I don’t want to burden my children; let me go peacefully,” framing non-prolongation as a parental duty rather than solely a personal wish. Similarly, F7 reflected, “I just want my mother not to suffer,” expressing a moral commitment to alleviating suffering over extending life at any cost. Healthcare providers observed that these priorities consistently guided discussions: “Almost everyone says they want comfort, not prolongation” (H8).

Participants described a good death as one characterized by peace, non-burden, and maintaining harmony within the family. Analytically, these patterned meanings align with a culturally grounded, relational understanding of dignity. In this Thai context, dignity did not emerge as individual autonomy, but as dying in a way that preserves composure, minimizes disruption, and protects loved ones. Thus, good death in participants’ accounts can be interpreted as death with relational dignity, grounded in moral responsibility rather than self-determination.

Spiritual practices reinforced this orientation. One family caregiver described how the patient engaged in chanting as her illness progressed: “When my mom’s illness got worse, she chanted so her mind would be peaceful” (F5). In this account, spiritual practice functioned as a means of cultivating composure and acceptance. Healthcare providers described intentionally using language such as “letting go” (H2) to support emotional acceptance of decline. Rather than presenting decisions as treatment limitation, this framing positioned non-prolongation as compassionate care aligned with participants’ desire for peace and non-burden.

Subtheme 2.2 place of care, safety, and family harmony

Preferences regarding place of death were shaped by relational considerations of safety and family wellbeing. Decisions about home versus hospital care were discussed not only in practical terms, but in relation to protecting family caregivers emotionally and preserving stability within the household.

Although home was often described as ideal, many participants felt it was impractical due to safety concerns or caregiving limitations. P9 noted, “Home would be best, but I’m afraid no one will be there when it gets bad.” Others preferred hospital care to shield family caregivers from traumatic memories: “I don’t want them to remember the house with fear” (P6). Families described logistical strain (F8), and healthcare providers acknowledged structural limitations affecting continuity of care (H9).

Maintaining harmony also influenced conversational boundaries. Some participants avoided direct discussion because “it would make others cry” (P5, F2). Providers observed that patients sometimes deflected the topic to reduce emotional discomfort (H9). Even during culturally significant periods such as New Year, discussing death was perceived as socially inappropriate. These norms shaped when and how ACP could be discussed without disrupting relational equilibrium.

Subtheme 2.3 life completion, rituals, and preparation actions

Participants described that engaging in ACP often prompted reflection beyond medical decisions. Discussing future care brought attention to preparation for death and its relational consequences, including family conflict, financial disorder, and emotional disruption. In this sense, ACP functioned as a catalyst for broader life completion rather than a stand-alone medical conversation.

Emotional preparation referred to gradually accepting mortality and feeling more at ease when discussing decline. Practical preparation referred to organizing assets, clarifying inheritance, arranging funeral plans, and preventing future disputes. These actions were frequently discussed during or immediately after ACP conversations. P3 explained, “I made my will already, so it won’t be chaotic later. I feel less worried when we talk about advance care planning because I have already arranged things.” Similarly, F1 described settling land ownership before death to avoid disputes. Healthcare providers observed that when patients had organized personal matters, they appeared more open and less anxious during ACP discussions (H6). Thus, preparatory actions not only followed ACP but also facilitated more confident participation in it.

Spiritual and cultural practices were likewise embedded within ACP encounters, particularly when illness worsened or sensitive decisions were being discussed. Inviting monks to chant (F4) or using herbal remedies for comfort (P1) were described as ways to cultivate calm while engaging in difficult conversations. Within ACP discussions, this sometimes created negotiation between honoring spiritual priorities and responding to clinical urgency. Participation in ACP therefore involved balancing spiritual, relational, and medical preparation rather than treating them as separate domains.

Theme 3 communication as relational positioning in ACP

This theme examines how healthcare providers’ communication shaped patients’ and family caregivers’ participation in ACP. Participants emphasized that engagement depended not only on the content of discussion, but on how conversations were initiated, framed, and paced, and how decision-making responsibility was positioned within families.

When healthcare providers introduced ACP gradually and acknowledged emotional responses, patients and families described feeling supported and able to engage. In contrast, abrupt or directive communication led to discomfort, withdrawal, or avoidance. Communication style therefore influenced whether ACP was experienced as collaborative or overwhelming.

Family-centred decision roles also shaped participation. Decisions were often negotiated collectively, and responsibility for speaking or deciding was distributed within the family. This affected who engaged in discussion and when conversations proceeded.

Subtheme 3.1 tone, framing, and the emotional pace of disclosure

Healthcare professionals’ communication style significantly shaped participants’ willingness to remain engaged in ACP discussions. Tone, pacing, and framing influenced whether conversations were experienced as compassionate dialogue or as distressing confrontation.

Patients valued honest yet gentle delivery. P5 described, “The doctor spoke frankly but gently, that made me able to keep talking.” In contrast, blunt communication disrupted emotional stability. P7 reflected, “The doctor said it too bluntly… they should read the timing,” suggesting that sensitivity to emotional context was critical.

Participants also described what could be understood as crisis framing, introducing ACP primarily through urgent, binary decisions during acute moments, such as asking, “Do you want CPR?” (F3). When discussions were framed narrowly around immediate life-sustaining choices, they felt sudden and transactional, limiting space for reflection or shared understanding.

By contrast, pacing involved introducing sensitive topics gradually over time rather than in a single encounter. Empathy involved acknowledging fear, uncertainty, or family concerns before discussing options. Respect involved recognizing relational roles, such as waiting for key family caregivers to be present or allowing patients to signal readiness. When these practices were present, participants described feeling more able to continue the conversation. Communication therefore influenced whether emotional readiness could develop or whether it fragmented under pressure.

Subtheme 3.2 responsibility, authority, and interdisciplinary roles in initiating ACP

Across interviews, a consistent pattern emerged: initiation and continuation of ACP were shaped by different forms of professional authority. Communication was structured not only by style, but by institutional hierarchy and relational positioning within interdisciplinary teams.

Physicians were positioned as holding formal decision-making authority and were therefore expected to introduce ACP discussions, particularly those concerning life-sustaining treatment. Several patients stated they “wouldn’t know how to start” the discussion (P1, P5), framing initiation as a professional responsibility. Families expressed concern when ACP was not raised: “The doctor never brings it up” (F10). Participation therefore depended partly on clinicians’ authority and willingness to initiate.

In contrast, nurses were described as sustaining and deepening conversations through relational continuity, emotional pacing, and repeated everyday encounters. As H6 noted, “Doctors give facts; nurses add empathy.” Their ongoing proximity strengthened trust and allowed discussions to unfold gradually (H9). Through this relational continuity, nurses bridged formal medical authority and family-level emotional readiness. Some nurses increasingly coordinated ACP discussions (H2), reflecting evolving interdisciplinary roles.

Thus, authority determined who could formally initiate ACP, while relational continuity shaped whether conversations deepened and persisted over time.

Theme 4 structural conditions shaping the possibility of ACP

This theme captures how organizational and systemic conditions influenced whether readiness and communication practices could translate into sustained ACP engagement. Even when patients and families expressed willingness to participate, structural constraints, including economic pressure, training gaps, workload, and hierarchy, shaped the feasibility and timing of conversations. ACP was therefore embedded within institutional realities that either enabled proactive dialogue or reinforced reactive patterns of engagement.

Subtheme 4.1 economic and resource limits shaping ACP decisions

Across accounts, economic realities narrowed what ACP could realistically promise, shaping planning within constrained options. Financial and logistical pressures directly influenced care decisions discussed within ACP conversations. Economic strain affected treatment continuation, caregiving capacity, and the feasibility of preferred care settings.

P8 stated, “The cancer medication was too expensive; I had to stop it,” illustrating how financial realities shaped treatment trajectories. Families described repeated hospital visits as burdensome: “I have to take leave every time I accompany mom” (F8). Healthcare providers noted limited community-based services, which restricted continuity of care and constrained options for home support. These constraints narrowed available choices and defined the practical boundaries within which ACP planning could occur.

Subtheme 4.2 limited preparation and hesitant initiation

Healthcare providers described gaps in training and confidence that influenced their engagement in ACP discussions. Several expressed discomfort initiating sensitive conversations.

H4 explained, “We need workshops to practice real conversations,” highlighting perceived limitations in experiential preparation. Others feared “saying the wrong thing” (H3), reflecting concern about causing distress or damaging trust. Limited formal training reduced confidence and contributed to hesitancy.

In this way, structural investment in communication preparation influenced whether professionals felt equipped to initiate ACP or whether discussions were postponed. This recurring hesitation reflected structural gaps in experiential preparation rather than individual reluctance.

Subtheme 4.3 hierarchy and workload reinforcing reactive ACP

Institutional hierarchy and workload pressures further shaped ACP initiation. Traditional role expectations positioned physicians as primary decision-makers, while heavy clinical demands limited opportunities for proactive engagement.

As H5 observed, “There’s too much work, and we have to wait for the doctor to start.” High patient volumes and hierarchical norms reinforced reactive patterns of initiation. Even when nurses recognized opportunities for discussion, some deferred due to institutional structure (P6).

These accounts collectively indicate that hierarchy and workload structured ACP as reactive rather than proactive, often delaying dialogue until crisis intervened.

Discussion

This study advances a contextualized conceptualization of readiness as a multidimensional and relationally negotiated construct shaping when and how ACP becomes possible. Drawing on triadic perspectives from patients, family caregivers, and healthcare providers in a Thai tertiary palliative care context, we demonstrate that ACP does not unfold as a linear, document-focused intervention. Rather, it becomes practicable when emotional, familial, and structural readiness converge sufficiently to sustain dialogue. Participation was not determined by disease stage alone, but by the degree of alignment across these interacting domains.

Across the themes, readiness emerged not as chronological timing but as a relational and institutional condition that rendered timing acceptable. As illustrated in Theme 1 (Timing and pathways into ACP), participants described delaying conversations until emotional shock subsided or trust had developed, indicating that readiness was tied to emotional stabilization rather than clinical milestones alone. In Theme 3 (Communication and relational decision-making), participants further emphasized pacing, empathy, and gradual disclosure as necessary conditions for engagement. Together, these patterns suggest that participation required sufficient emotional tolerance before dialogue could be sustained.

In this study, readiness comprised three interrelated domains. Emotional readiness referred to the capacity of patients and families to tolerate conversations about decline without becoming overwhelmed. This domain was derived from recurring descriptions of shock, fear, avoidance, and the need for gentle pacing before discussions could proceed meaningfully. Emotional readiness developed relationally through trust-building and repeated encounters rather than emerging at a fixed point in the illness trajectory.

Familial readiness reflected the collective willingness to negotiate preferences while preserving harmony and protecting one another from distress. Across Themes 2 and 3, family caregivers described avoiding burden, maintaining peace, and safeguarding children from emotional disruption. Decision-making was articulated through relational language, illustrating relational autonomy in practice [14–16]. Autonomy was enacted through connectedness rather than independence. In this context, readiness required shared emotional tolerance and negotiated consensus rather than individual acceptance alone.

Structural readiness referred to whether institutional conditions enabled proactive and sustained dialogue. As reflected in Theme 4, participants identified heavy workload, hierarchical authority structures, limited experiential training, and constrained community resources as shaping when and how ACP could occur. Even when emotional openness was present, conversations could be delayed by uncertainty regarding professional roles or lack of protected discussion time. Structural readiness thus represented institutional enablement rather than personal disposition.

ACP participation became most feasible when emotional tolerance, familial consensus, and structural opportunity aligned. When misaligned, for example, when emotional hesitation intersected with hierarchical delay or resource limitation, conversations were deferred. In such situations, crisis functioned as a structural override, compelling engagement that had previously been postponed. Importantly, readiness in this model is not synonymous with early timing; rather, it reflects the alignment of relational and institutional conditions that make earlier timing possible.

We therefore conceptualize readiness as a dynamic alignment model in which emotional tolerance (patient–family), familial consensus (relational negotiation), and structural enablement (institutional capacity) converge to render ACP dialogue sustainable. Misalignment across any domain results in deferral, while crisis temporarily overrides insufficient alignment. This interpretive synthesis helps explain why ACP remained predominantly crisis-triggered despite broad endorsement of early planning.

Alignment was negotiated relationally rather than individually declared. Timing was jointly calibrated through interaction rather than determined solely by clinical thresholds. Although participants endorsed early planning in principle, conversations were often delayed until emotional shock subsided, trust developed, or urgency intervened. This resonates with findings from other Asian contexts where concern about undermining hope and uncertainty about the “right time” constrain early dialogue [9, 31]. Communication practices mediated alignment: gentle framing, acknowledgment of fear, and paced disclosure supported engagement, whereas abrupt or transactional approaches disrupted it.

Professional roles were similarly negotiated within hierarchical norms. Physicians were expected to initiate formal discussions regarding life-sustaining treatment, reflecting patterns documented in Asian healthcare systems [9]. However, nurses frequently sustained and deepened conversations by embedding ACP within routine care interactions. Their continuity of presence enabled emotional pacing and relational trust-building. Within hierarchical systems where physicians hold formal decision-making authority, nurses functioned as relational infrastructure, maintaining alignment across readiness domains over time. This distinction between formal clinical authority and relational authority underscores the importance of interdisciplinary role clarity in ACP implementation.

Importantly, the persistence of crisis-triggered ACP cannot be attributed solely to cultural taboo. Late initiation of ACP has been documented across diverse health systems [4, 32]. Rather than positioning collectivism as a barrier, our findings suggest that Thai relational ethics shape how readiness is interpreted and negotiated. Emphasis on non-burden, peace, and family protection reflects culturally embedded moral reasoning [20]. Spiritual practices supported emotional acceptance and preparation, consistent with literature linking spirituality and end-of-life engagement [7, 12]. Collectivism thus provided a moral framework for ACP engagement rather than preventing it.

Conceptualizing readiness as multidimensional reframes implementation priorities. Earlier timing alone is insufficient if emotional, familial, and structural conditions remain misaligned. Sustainable change requires interventions that cultivate emotional tolerance, support family-level dialogue, clarify interdisciplinary responsibility, and address structural barriers such as workload and continuity gaps.

Interpretation was shaped by researcher positioning. The first author’s background as a nurse researcher familiar with Thai healthcare hierarchies likely heightened analytic sensitivity to relational dynamics and the facilitative role of nurses. Consistent with reflexive thematic analysis principles [24, 25], themes were developed through iterative team dialogue and reflexive memoing, recognizing findings as interpretive constructions rather than objective discoveries. Translation from Thai to English prioritized conceptual equivalence [29], acknowledging that relational nuances embedded in language required careful interpretive attention.

Strengths and limitations

A key strength of this study lies in its triadic design, integrating patient, family caregiver, and healthcare provider perspectives within a shared care context. This enabled analytic comparison across stakeholder positions and illuminated ACP as a relationally negotiated practice rather than an individually enacted decision. The use of reflexive thematic analysis within a contextualist critical realist framework supported coherent interpretive development, with reflexive journaling and iterative team dialogue enhancing analytic transparency.

Several limitations warrant consideration. The single-site tertiary setting, where ACP services were already established, may limit transferability to non-specialist, community, or rural contexts where structural readiness differs substantially. Because many interviews occurred during advanced illness, the findings may foreground late-stage and crisis-triggered experiences, potentially underrepresenting earlier phases of readiness development. Expressions of spiritual acceptance may have been influenced by social desirability. Although translation prioritized conceptual equivalence, some nuances of Thai relational language may not be fully captured in English.

Recommendations

Strengthening ACP implementation requires coordinated attention to emotional, familial, and structural readiness rather than focusing solely on documentation or individual attitudes. Practice models should incorporate structured, yet flexible readiness assessment embedded within routine clinical encounters, allowing conversations to evolve gradually rather than being deferred to crisis contexts.

Communication training should extend beyond procedural instruction to include culturally attuned pacing, relational framing, and interdisciplinary coordination. Given the facilitative role observed among nurses, implementation strategies should formally recognize and resource nurse-led or nurse-sustained ACP conversations within hierarchical systems. At the system level, protected discussion time, strengthened community-based palliative services, and integration within electronic health records are essential to support continuity across care transitions.

Interventions addressing only one readiness domain are unlikely to produce sustained change. Alignment across domains must be intentionally cultivated.

Conclusion

This study conceptualizes ACP as a relationally negotiated practice contingent upon the alignment of emotional, familial, and structural readiness. Within a collectivist and hierarchical healthcare context, ACP remains predominantly crisis-triggered not because of cultural resistance alone, but because readiness domains rarely converge before clinical urgency intervenes. Crisis functions as a temporary structural override in the absence of prior alignment.

Recognizing readiness as multidimensional reframes implementation from a question of timing to one of relational and institutional coordination. Sustainable ACP engagement requires deliberate cultivation of emotional pacing, family dialogue, interdisciplinary role clarity, and structural support. Without such alignment, ACP is likely to remain reactive despite widespread acknowledgment of its value.

Authors' contributions

Conceptualization: Apiradee Pimsen Data curation: Supinda RuangjiratainFormal analysis: Apiradee Pimsen, Nedruetai PunaglomFunding acquisition: Siriluk WinitchayothinInvestigation: Apiradee Pimsen, Siriluk WinitchayothinMethodology: Anuwat Taweesuwanakrai, Wanida WinyoohatthakitProject administration: Wanida Winyoohatthakit, Apiradee Pimsen Resources: Virapun Wirojratana Supervision: Virapun WirojratanaValidation: Virapun Wirojratana Writing – original draft: Supinda Ruangjiratain, Apiradee Pimsen Writing – review and editing: Ahmad Rifai, Nedruetai Punaglom.

Funding

Open access funding provided by Mahidol University. This research project was supported by the China Medical Board of New York, Inc., through the Faculty of Nursing, Mahidol University, Thailand. The funder had no role in study design, data collection, analysis, interpretation, manuscript writing, or the decision to submit for publication.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to the inclusion of information that could compromise participant confidentiality but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Approved by Mahidol University Multi-Faculty Cooperative IRB (MU-MOU-IRB-NS2024/76.2910). Written informed consent obtained from all participants. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and relevant ethical guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.