Assessment of advance care planning readiness and its determinants among peritoneal dialysis patients in China

Abstract

Advance care planning (ACP) is essential for respecting patient autonomy and improving end-of-life care quality. However, the level of ACP readiness and its determinants among individuals receiving peritoneal dialysis (PD) in China remain insufficiently explored. This study employed a cross-sectional descriptive-analytical design. From January to June 2025, 129 adults receiving PD were recruited using convenience sampling from two tertiary hospitals in Sichuan Province, China. Demographic characteristics, including age, sex, marital status, educational level, employment status, disease duration, dialysis duration, and comorbidities, were collected. ACP readiness was assessed using the Chinese version of the Advance Care Planning Readiness Scale (ACPRS), which has demonstrated good reliability and validity in Chinese chronic disease populations. Death anxiety and social support were measured using the Chinese versions of the Templer Death Anxiety Scale (CT-DAS) and the Social Support Rating Scale (SSRS), respectively. Multiple linear regression analysis was conducted after verifying assumptions of normality, homoscedasticity, and absence of multicollinearity. The mean ACP readiness score was 65.89 ± 14.07 (range: 22–110), indicating a moderately low level of readiness. In the final regression model, longer dialysis duration (B = 3.43, p = 0.015), a greater number of comorbidities (B = 2.72, p = 0.028), and higher social support (B = 0.55, p = 0.040) were positively associated with ACP readiness, whereas higher death anxiety was negatively associated with ACP readiness (B = − 1.03, p = 0.026). The final model explained 31.6% of the variance in ACP readiness (adjusted R² = 0.270). ACP readiness among individuals receiving PD in China remains suboptimal and is shaped by clinical burden, psychosocial resources, and death-related emotional responses. Reduced ACP readiness may hinder timely end-of-life decision-making and increase the decisional burden on families. Interventions should focus on strengthening social support, addressing death anxiety, and integrating culturally sensitive ACP discussions into routine PD care. These findings underscore the importance of context-specific ACP strategies within the sociocultural framework of China.

Introduction

Kidney failure, the terminal stage of chronic kidney disease, represents a major global public health burden due to its high morbidity, mortality, and long-term treatment demands¹. In China, more than 1.02 million patients currently rely on dialysis therapy to sustain life, among whom peritoneal dialysis (PD) has become an increasingly important renal replacement modality because of its flexibility, preservation of residual renal function, and suitability for long-term home-based care^2,3.

Despite these advantages, individuals receiving PD face substantial and sustained challenges across physical, psychological, and social domains. Long-term dialysis is frequently accompanied by symptom burden such as fatigue, sleep disturbances, and pain, as well as psychological distress including anxiety, depression, and uncertainty regarding prognosis^4,5. Moreover, the home-based nature of PD shifts a considerable proportion of disease management responsibility from healthcare professionals to patients and their families, increasing the demands for self-management, health literacy, and autonomous decision-making. As the disease progresses and complications accumulate, individuals receiving PD are increasingly confronted with complex decisions regarding treatment goals, life-sustaining interventions, and end-of-life care.

Advance care planning (ACP) is a structured process that supports individuals in reflecting on and communicating their values, goals, and preferences for future medical care, particularly in situations where decision-making capacity may be compromised^6–8. A growing body of evidence indicates that ACP can improve alignment between care received and patient preferences, reduce unnecessary aggressive treatments, and alleviate decisional burden on family members^9,10. Consequently, ACP is increasingly recognized as a core component of high-quality palliative and end-of-life care for patients with chronic, life-limiting illnesses.

However, engagement in ACP is not a binary phenomenon but rather a dynamic process influenced by individuals’ readiness, which encompasses attitudes, beliefs, and motivation toward planning for future care. Previous studies in patients with advanced cancer, dementia, and chronic organ failure have demonstrated that ACP readiness varies substantially across populations and is shaped by clinical characteristics, psychosocial resources, cultural norms, and emotional responses to death^11–14. In China, ACP implementation remains at an early stage, with limited public awareness and significant sociocultural barriers, including death-related taboos and family-centered decision-making traditions¹⁵. Existing research has primarily focused on broader CKD populations with kidney failure requiring dialysis or on hemodialysis patients, with limited attention to PD-specific contexts¹⁶.

Importantly, individuals receiving PD may differ fundamentally from other CKD populations with kidney failure requiring dialysis in their need for and approach to ACP. Unlike hemodialysis, which is typically delivered in hospital-based settings with regular professional supervision, PD is predominantly performed at home and relies heavily on patients’ self-management capabilities. This autonomy-oriented treatment model exposes individuals receiving PD to unique risks, such as infection, treatment failure, and sudden clinical deterioration, often occurring outside hospital environments. Consequently, individuals receiving PD and their families may be required to make urgent medical decisions under conditions of limited professional guidance, underscoring the importance of prior clarification of care preferences through ACP.

Despite these distinctive characteristics, empirical evidence regarding ACP readiness specifically among individuals receiving PD remains scarce. Existing research has primarily focused on broader CKD populations with kidney failure requiring dialysis or on hemodialysis patients, with limited attention to PD-specific contexts¹⁶. It remains unclear what level of ACP readiness individuals receiving PD demonstrate, which factors most strongly influence their preparedness, and how psychosocial variables such as social support and death anxiety interact with clinical characteristics to shape readiness. Furthermore, few studies have systematically examined ACP readiness using validated measurement tools within the sociocultural context of mainland China.

To address these gaps, the present study aimed to assess the level of ACP readiness among individuals receiving PD in China and to identify its key determinants. By examining demographic, clinical, and psychosocial factors—including social support and death anxiety—this study seeks to provide empirical evidence to inform culturally sensitive, PD-specific ACP interventions and to support patient-centered end-of-life care planning in this growing population.

Methods

Study design & study participants

This study adopted a cross-sectional descriptive-analytical design to assess the level of advance care planning (ACP) readiness and its associated factors among individuals receiving peritoneal dialysis (PD). A cross-sectional approach was selected to provide an initial empirical overview of ACP readiness in a population for which limited evidence is currently available.

A convenience sampling strategy was employed to recruit participants from the nephrology outpatient and inpatient departments of two tertiary general hospitals in Sichuan Province, China, between January and June 2025. Probability-based sampling was not feasible due to the relatively limited number of stable individuals receiving PD who met the inclusion criteria, logistical constraints within clinical settings, and the need to ensure continuous dialysis care without disrupting routine treatment. The implications of convenience sampling for external validity and generalizability are acknowledged and discussed in the Limitations section.

Participants and inclusion/exclusion criteria

Eligible participants met the following inclusion criteria:

1. Diagnosis of stage 5 chronic kidney disease according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines¹⁷;

2. receipt of peritoneal dialysis for at least 3 months;

3. age ≥ 18 years;

4. clear consciousness and adequate communication ability, defined as a Glasgow Coma Scale (GCS) score of 15.

Exclusion criteria included:

1. severe acute complications or terminal-stage conditions;

2. major psychiatric disorders or clinically diagnosed cognitive impairment documented in medical records;

3. receipt of combination dialysis, defined as patients who required intermittent or sustained hemodialysis in addition to PD due to PD failure or inadequate clearance.

Sample size estimation

Sample size estimation was based on recommendations for multiple linear regression analysis, which suggest a minimum of 5–10 observations per predictor variable¹⁸. In this study, 21 candidate variables (including demographic, clinical, and psychosocial predictors) were initially considered for regression modeling, resulting in an estimated minimum sample size of 105–210 participants. Assuming a 10% invalid or incomplete response rate, the target sample size ranged from 116 to 230 participants. Ultimately, 129 valid questionnaires were included in the final analysis, meeting the minimum requirements for regression analysis.

Instruments

General information questionnaire

A self-designed questionnaire was used by the researchers to collect demographic data, including gender, age, educational level, marital status, employment status, years since kidney disease diagnosis, duration of dialysis, and daily dialysis dose.

The advance care planning readiness scale (ACPRS)

The ACPRS was developed by Wang Xinru et al.¹⁹ based on China’s cultural context to quantify an individual’s readiness for advance care planning. In this study, ‘readiness’ refers to an individual’s attitude, belief, and motivation toward engaging in advance care planning (ACP), including willingness to discuss future care decisions and to involve family members in these discussions.The scale consists of 22 items, divided into three dimensions: attitude (10 items), belief (7 items), and motivation (5 items). Each item is rated on a 5-point Likert scale, where “strongly disagree” scores 1 point and “strongly agree” scores 5 points, with a total score range of 22 to 110. A higher score indicates greater readiness for ACP. ACP readiness is categorized into four levels: low (22 to < 44), moderately low (44 to < 66), moderately high (66 to < 88), and high (88 to 110). The attitude dimension is categorized into: low (10 to 21), moderately low (> 21 to 31), moderately high (> 31 to 41), and high (> 41 to 50); the belief dimension into: low (7 to 13), moderately low (> 13 to 21), moderately high (> 21 to 29), and high (> 29 to 35); and the motivation dimension into: low (5 to 10), moderately low (> 10 to 15), moderately high (> 15 to 20), and high (> 20 to 25). The Cronbach’s α coefficient of this scale is 0.923. In this study, the Cronbach’s α coefficient was 0.879.

Chinese version of the templer death anxiety scale (CT-DAS)

The CT-DAS was adapted by Yang Hong²⁰ based on the original Templer Death Anxiety Scale (T-DAS)²¹ to assess death anxiety in the Chinese population. The scale includes 15 items divided into four dimensions: emotion (items 1, 3, 5, 10, 13, 14), stress and distress (items 4, 6, 9, 11), time awareness (items 8, 12), and cognition (items 2, 7, 15). Items are answered with “yes” or “no,” scoring 1 for “yes” and 0 for “no.” Items 2, 3, 5, 6, 7, and 15 are reverse scored. The total score ranges from 0 to 15, with higher scores indicating more severe death anxiety, and a score of 7 or higher is considered indicative of high death anxiety. The Cronbach’s α coefficient of this scale is 0.713, and the test-retest reliability is 0.845. In this study, the Cronbach’s α coefficient was 0.790.

Social support rating scale (SSRS)

The SSRS, developed by Xiao Shuiyuan in 1986²², is used to assess the social support of patients. It includes three dimensions: objective support, subjective support, and utilization of support, with a total of 10 items. The objective support dimension includes items 2, 6, and 7; the subjective support dimension includes items 1, 3, 4, and 5; and the utilization of support dimension consists of items 8, 9, and 10. Items 1–4, 8–10 are single-choice questions, with options 1, 2, 3, and 4 corresponding to scores of 1, 2, 3, and 4 points, respectively. Item 5 scores the sum of responses, with scores ranging from 1 (no support) to 4 (full support). Items 6 and 7 are multiple-choice questions, with responses of “no source” scoring 0, and “multiple sources” scoring accordingly for each source. The total score is the sum of the scores of all 10 items, with a score range of 12 to 66, where higher scores indicate higher levels of social support. The Cronbach’s α coefficient of this scale in this study was 0.75.

Although the ACPRS, CT-DAS, and SSRS have demonstrated acceptable reliability and construct validity in previous studies conducted among Chinese chronic disease populations, no confirmatory factor analysis (CFA) was performed in the present peritoneal dialysis (PD) sample.

The CFA indices cited for these instruments were derived from their original development or prior validation studies, rather than from the current dataset. Therefore, in this study, the psychometric performance of the instruments was evaluated primarily through internal consistency reliability (Cronbach’s α), and their applicability to the PD population should be interpreted with caution.

Data collection

Data were collected using self-administered questionnaires. For participants with reading difficulties, trained interviewers read the items verbatim and recorded responses without interpretation. Two graduate nursing students received standardized training in survey administration, ethical procedures, and scale interpretation prior to data collection. Inter-rater consistency during training was assessed for questionnaire administration procedures, yielding a Kappa value of 0.89.Of the 140 questionnaires distributed, 129 were valid and complete. Missing data were minimal (< 5% per variable). Given the low proportion of missingness and the cross-sectional nature of the study, missing data were handled using listwise deletion in all statistical analyses. No data imputation methods (e.g., mean imputation) were applied.

Statistical analysis

Data were analyzed using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Descriptive statistics were used to summarize demographic, clinical, and psychosocial characteristics of the participants. Continuous variables were presented as mean ± standard deviation (SD), and categorical variables were expressed as frequencies and percentages.

Pearson correlation analysis was performed to examine the associations between advance care planning (ACP) readiness, death anxiety, and social support. Prior to regression analysis, assumptions of linearity, normality of residuals, homoscedasticity, independence, and absence of multicollinearity were assessed. Multicollinearity was evaluated using variance inflation factors (VIF), with all values below 5 indicating acceptable levels.

Multiple linear regression analysis was conducted to identify factors associated with ACP readiness. Given the exploratory nature of this study and the absence of established peritoneal dialysis-specific models of ACP readiness, a stepwise multiple linear regression approach was applied. Candidate variables entered into the model included demographic variables (age, sex, marital status, educational level, and employment status), clinical variables (duration of kidney disease diagnosis, dialysis duration, daily dialysis dose, and number of comorbidities), and psychosocial variables (death anxiety and social support). Binary categorical variables were dummy coded (0/1), and ordered categorical variables were entered as ordinal variables according to increasing clinical burden. In the final model, dialysis duration was coded as 1 = < 1 year, 2 = 1–5 years, and 3 = > 5 years, and number of comorbidities was coded as 0 = none, 1 = one, 2 = two, and 3 = three or more.

Variables were entered into or removed from the model based on statistical criteria, with an entry significance level of p < 0.05 and a removal level of p > 0.10. The final model retained variables that made statistically significant independent contributions to ACP readiness. Model fit was evaluated using the coefficient of determination (R²) and adjusted R². All statistical tests were two-tailed, and a p value of < 0.05 was considered statistically significant.

Results

Descriptive statistics of ACP readiness, death anxiety, and social support

Among the 129 participants receiving peritoneal dialysis included in the analysis, the total ACP readiness score ranged from 22 to 110, with a mean score of 65.89 ± 14.07, indicating an overall moderately low level of readiness. Based on the predefined cutoff values, 46.5% of participants were classified as having moderately low readiness, 38.0% as moderately high readiness, 9.3% as low readiness, and only 6.2% as high readiness.

For the ACP readiness subdimensions, attitude scores ranged from 10 to 50, with a mean of 29.79 ± 5.97, corresponding to a moderately low level. The belief dimension ranged from 7 to 35, with a mean score of 15.13 ± 3.70, which falls within the moderately low category rather than the moderately high category. Motivation scores ranged from 5 to 25, with a mean of 20.97 ± 6.66, also indicating a moderately low level of motivation. Detailed descriptive statistics, including minimum and maximum values, are presented in Table 1. The total death anxiety score (CT-DAS) ranged from 2 to 14, with a mean of 8.29 ± 2.68, suggesting a relatively high level of death anxiety among individuals receiving PD. Social support scores ranged from 28 to 54, with a mean of 39.33 ± 4.28, indicating a moderate level of perceived social support.

Table 1.

Descriptive statistics and readiness levels of ACPRS (n = 129, mean ± SD).

Dimension	Possible range	Mean ± SD	Readiness level
Total ACP readiness	22–110	65.89 ± 14.07	Moderately low
Attitude	10–50	29.79 ± 5.97	Moderately low
Belief	7–35	15.13 ± 3.70	Moderately low ✓
Motivation	5–25	20.97 ± 6.66	Moderately low

Between-group differences in ACP readiness

Univariate analyses revealed statistically significant differences in ACP readiness scores across age groups, marital status, duration of kidney disease diagnosis, dialysis duration, and number of comorbidities (p < 0.05; Table 2). In addition to statistical significance, effect sizes were calculated to assess practical relevance. The number of comorbidities showed the largest effect on ACP readiness (η² = 0.158), representing a large effect, whereas duration of kidney disease diagnosis showed a moderate effect (η² = 0.069). Age (η² = 0.047) and dialysis duration (η² = 0.054) showed small effects, and marital status showed a moderate effect (Cohen’s d = 0.538). These findings suggest that although several demographic and clinical factors were statistically associated with ACP readiness, the magnitude of their effects varied.

Table 2.

Comparison of ACP readiness scores by demographic characteristics of peritoneal dialysis patients.

Item	Classification	Number of cases (n, %)	Score (Mean ± SD)	Statistic	P	Effect Size (η²/Cohen’s d)
Gender	Male	67 (51.94)	67.16 ± 15.91	t = 1.081	0.282	Cohen’s d = 0.189
	Female	62 (48.06)	64.52 ± 11.75
Age	≤ 45 years	43 (33.33)	69.14 ± 14.98	F = 3.211	0.044	η²=0.047
	46–60 years	57 (44.19)	66.07 ± 13.53
	> 60 years	29 (22.48)	60.72 ± 12.61
Educational level	Primary school and below	39 (30.23)	69.69 ± 14.70	F = 1.664	0.178	η²=0.031
	Junior high school	67 (51.94)	64.37 ± 13.31
	Senior high school/technical secondary school	16 (12.40)	65.63 ± 15.58
	College and above	7 (5.43)	59.86 ± 11.80
Marital status	Married	114 (88.37)	67.93 ± 16.81	t=−3.032	0.003	Cohen’s d = 0.538
	Others	15 (11.63)	64.57 ± 13.20
Occupational status	Employed	44 (34.11)	68.95 ± 14.64	t = 1.794	0.075	Cohen’s d = 0.318
	Unemployed	85 (65.89)	64.31 ± 13.59
Duration of kidney disease diagnosis	< 1 year	27 (20.93)	58.70 ± 12.92	F = 4.765	0.010	η²=0.069
	1–5 years	21 (16.28)	66.95 ± 12.97
	> 5 years	81 (62.79)	68.01 ± 14.08
Dialysis duration	< 1 year	52 (40.31)	63.12 ± 13.78	F = 3.718	0.027	η²=0.054
	1–5 years	48 (37.21)	65.35 ± 13.42
	> 5 years	29 (22.48)	71.76 ± 14.39
Daily dialysis dose	< 3 bags	44 (34.11)	63.27 ± 14.41	F = 1.334	0.267	η²=0.020
	3–4 bags	75 (58.14)	67.57 ± 13.97
	> 4 bags	10 (7.75)	64.80 ± 12.76
PD mode (merged)	CAPD + APD	129 (100.00)	65.91 ± 14.01	-	-	-
Number of comorbidities	0	35 (27.13)	59.57 ± 12.32	F = 7.138	< 0.001	η²=0.158 (large effect)
	1	48 (37.21)	64.33 ± 12.75
	2	27 (20.93)	70.22 ± 9.91
	≥ 3	19 (14.73)	75.32 ± 18.70

Given the small sample size of participants receiving automated peritoneal dialysis (APD, n = 7), comparisons by dialysis modality were interpreted cautiously and were not included as candidate predictors in subsequent regression analyses.

Correlations between ACP readiness and psychosocial variables

Pearson correlation analysis was conducted to examine the relationships between advance care planning (ACP) readiness and key psychosocial variables (Table 3). ACP readiness was positively correlated with overall social support (r = 0.29, p < 0.01), with subjective support showing the strongest association (r = 0.36, p < 0.01). In contrast, death anxiety was negatively correlated with ACP readiness (r = − 0.37, p < 0.01). These results indicate that higher perceived social support is associated with greater ACP readiness, whereas higher levels of death anxiety are associated with lower readiness.

Table 3.

Correlations between ACP readiness and key psychosocial variables.

Variable	ACP readiness (r)
Social support	0.29**
Subjective support	0.36**
Death anxiety	−0.37**

Factors associated With ACP readiness

Stepwise multiple linear regression analysis was performed to identify independent factors associated with advance care planning (ACP) readiness (Table 4). In the regression model, dialysis duration was entered as an ordinal variable coded 1 = < 1 year, 2 = 1–5 years, and 3 = > 5 years, and number of comorbidities was coded 0 = none, 1 = one, 2 = two, and 3 = three or more. Based on the standardized coefficients (β), dialysis duration (β = 0.19, p = 0.015), number of comorbidities (β = 0.20, p = 0.028), and social support (β = 0.17, p = 0.040) were positively associated with ACP readiness, whereas death anxiety was negatively associated with ACP readiness (β = −0.20, p = 0.026). The final regression model explained 31.6% of the variance in ACP readiness (R² = 0.316), with an adjusted R² of 0.270.

Table 4.

Linear regression analysis of influencing factors of ACP readiness in peritoneal dialysis patients.

Predictor	B	SE	β	95% CI	P
Death anxiety	−1.03	0.46	−0.20	−1.94 to − 0.12	0.026
Social support	0.55	0.27	0.17	0.03 to 1.07	0.040
Dialysis duration	3.43	1.39	0.19	0.68 to 6.18	0.015
Comorbidities	2.72	1.22	0.20	0.30 to 5.14	0.028

Model statistics: R² = 0.316; adjusted R² = 0.270.

Discussion

ACP readiness among individuals receiving peritoneal dialysis

This study found that advance care planning (ACP) readiness among individuals receiving peritoneal dialysis (PD) in China was at a moderately low level, with a mean ACPRS score of 65.89 ± 14.07. After applying established cutoff criteria, all three ACPRS subdimensions—attitude, belief, and motivation—were classified as moderately low, indicating that limited readiness reflects a multidimensional pattern rather than deficits in a single domain.

When compared with other populations, this finding is broadly consistent with studies conducted among individuals with chronic kidney disease (CKD), which have reported generally suboptimal levels of ACP engagement and preparedness, particularly in settings where ACP is not routinely integrated into standard care^23,24. However, the level of ACP readiness observed in this PD cohort appears lower than that reported in several studies of individuals receiving in-center hemodialysis, in which readiness and engagement have often been described as moderate to moderately high^25,26. These differences suggest that ACP readiness may vary across kidney replacement therapy modalities.

Several contextual factors may contribute to the relatively low ACP readiness observed in this study. From a sociocultural perspective, traditional taboos surrounding discussions of death and a strong family-centered decision-making model may reduce individuals’ willingness to proactively engage in advance care planning conversations¹⁵. In addition, the absence of widespread legal recognition and standardized implementation of advance directives in mainland China may further limit perceived feasibility and value of ACP, thereby weakening motivation to engage in formal planning²⁷.

Importantly, peritoneal dialysis represents one modality within the broader spectrum of kidney replacement therapies (KRT), which also includes hemodialysis and kidney transplantation. Each KRT modality involves distinct care environments, treatment demands, and professional support structures, which may differentially influence ACP engagement^28,29. Compared with hospital-based hemodialysis, PD is predominantly home-based and relies heavily on individuals’ self-management capacity, technical competence, and sustained family involvement.

While this autonomy-oriented treatment model offers advantages such as flexibility and preservation of residual kidney function, it also places substantial cognitive, technical, and emotional demands on individuals receiving PD. Ongoing challenges—including the risk of peritonitis, concerns regarding technique survival, uncertainty about long-term treatment outcomes, and the continuous responsibility for self-monitoring—may lead individuals to prioritize immediate disease management over future-oriented discussions^4,5,12. As a result, opportunities for structured, clinician-led ACP conversations may be reduced, which may partly explain the lower readiness observed in this population compared with individuals receiving facility-based dialysis.

Taken together, these findings suggest that ACP readiness among individuals receiving PD should be interpreted within the combined context of sociocultural norms, healthcare system factors, and treatment-specific demands. The relatively low readiness identified in this study may not reflect a lack of concern for future care, but rather the complex realities of living with a self-managed, life-sustaining therapy. Recognizing these contextual influences is essential for developing PD-specific, person-centred approaches to advance care planning that align with individuals’ lived experiences and care priorities.

Interpretation of subdimension patterns and cognitive–behavioral gap

Although all ACPRS subdimensions were classified as moderately low, attitude and motivation scores were particularly limited relative to belief. This pattern suggests that individuals receiving PD may conceptually acknowledge the importance of ACP while lacking sufficient willingness or initiative to engage in concrete planning behaviors. It should be noted that this cognitive–behavioral gap was not directly measured as an independent construct in the present study but was inferred from the differential distribution of ACPRS subdimension scores.

Therefore, this interpretation should be understood as a theoretical integration of study findings rather than a direct empirical conclusion. Nevertheless, similar discrepancies between ACP awareness and behavioral engagement have been reported in prior studies of patients with chronic and life-limiting illnesses^30,31, supporting the plausibility of this interpretation.

Demographic and clinical factors associated with ACP readiness

In univariate analyses, ACP readiness differed significantly across age groups, marital status, duration of kidney disease diagnosis, dialysis duration, and number of comorbidities. However, after adjustment in the multivariate regression model, only dialysis duration and number of comorbidities remained independently associated with ACP readiness. These findings suggest that the apparent effects of certain demographic characteristics may be attenuated or mediated by clinical burden and treatment experience, rather than acting as direct determinants of readiness^23,24.

With respect to age, younger individuals demonstrated higher ACP readiness scores in univariate analysis. This association may reflect age-related differences in cognitive functioning, communication preferences, and openness to discussing health-related issues. Previous studies have suggested that individuals at earlier life stages may be more willing to engage in discussions involving personal or sensitive health topics, including treatment-related quality-of-life concerns and future care planning³². This openness may be partly attributable to relatively preserved cognitive capacity and information processing efficiency. Nevertheless, evidence regarding age-related differences in ACP engagement remains mixed, and age should therefore be interpreted as a contextual factor rather than a direct determinant of ACP readiness²⁴.

Marital status was also associated with ACP readiness in univariate analysis, with married individuals demonstrating higher readiness scores. This finding may be explained by the presence of spousal support and increased opportunities for communication about future care preferences. However, the effect of marital status did not persist in the multivariate model, suggesting that its influence may operate indirectly through psychosocial mechanisms rather than functioning as an independent predictor of ACP readiness²³.

Clinical characteristics appeared to play a more prominent role in shaping ACP readiness.

Longer dialysis duration was positively associated with higher ACP readiness, which may reflect greater exposure to treatment-related experiences and disease-related uncertainty over time. Over time, accumulated treatment experiences and encounters with complications may prompt reflection on future care needs and increase receptiveness to advance care planning³³.

A greater number of comorbidities was independently associated with higher ACP readiness, potentially reflecting greater illness burden and perceived relevance of future-oriented care planning. Individuals with multiple comorbid conditions often experience increased symptom burden and more complex healthcare trajectories, which may heighten perceived vulnerability and the relevance of future-oriented care planning. This finding is consistent with previous research demonstrating that greater illness severity and cumulative health challenges are associated with increased engagement in ACP-related considerations³⁴.

Taken together, these results indicate that while demographic factors such as age and marital status may be associated with ACP readiness at a descriptive level, clinical burden and treatment experience appear to exert a more substantial influence on readiness among individuals receiving peritoneal dialysis. These findings highlight the importance of prioritizing clinical indicators—such as dialysis duration and comorbidity burden—when identifying individuals who may benefit most from timely and tailored ACP discussions.

Pre-dialysis ACP screening and early identification of readiness

In addition to individual-level determinants, growing evidence from international settings highlights the importance of early and systematic identification of advance care planning readiness prior to dialysis initiation³⁵. Several countries have incorporated structured ACP screening or assessment tools into pre-dialysis care pathways to facilitate timely conversations about goals of care, treatment preferences, and future planning^36,37. These approaches aim to identify individuals’ readiness for ACP discussions at an earlier stage of kidney disease, before the clinical and emotional burden of dialysis becomes overwhelming.

Studies from Europe, North America, and Australia suggest that pre-dialysis ACP screening can improve patient engagement, enhance communication between individuals and kidney care teams, and support more proactive and values-based decision-making^35–37. By normalizing ACP discussions early in the disease trajectory, such strategies may reduce decisional burden on families and improve alignment between care preferences and treatment decisions.

In the Chinese context, ACP implementation remains limited and is often initiated late in the disease course or during acute clinical deterioration. Introducing structured ACP screening tools in the pre-dialysis phase may offer a feasible and culturally sensitive approach to promote earlier engagement, particularly for individuals who later transition to home-based therapies such as peritoneal dialysis. Future research should explore the acceptability and effectiveness of integrating pre-dialysis ACP screening into routine kidney care pathways in China.

Role of social support in enhancing ACP readiness

Social support emerged as a significant positive predictor of ACP readiness (β = 0.17), with subjective support showing the strongest correlation with readiness scores. This finding suggests that emotional and relational resources are associated with greater engagement in ACP-related considerations. Patients who perceive stronger support from family members and healthcare professionals may feel more secure discussing sensitive topics related to future care and end-of-life preferences.

While the present study did not directly evaluate specific intervention models, the observed association between social support and ACP readiness provides empirical justification for family- and clinician-involved approaches to ACP promotion. This interpretation is further supported by prior studies demonstrating that structured family–clinician communication can improve ACP engagement and reduce decisional burden in patients with chronic illnesses³⁸. Therefore, recommendations regarding collaborative support strategies are grounded in both the current data and existing evidence, rather than being purely speculative.

Health literacy and ACP readiness

Although health literacy was not directly measured in the present study, it represents a well-established factor influencing decision-making and self-management among persons living with chronic kidney failure. Health literacy refers to an individual’s capacity to obtain, understand, and apply health-related information to make informed decisions. This capability is particularly relevant to advance care planning, which requires comprehension of prognosis, treatment options, and potential future care scenarios³⁹.

Previous research in chronic kidney disease populations has consistently shown that limited health literacy is associated with poorer understanding of disease progression, reduced engagement in shared decision-making, and lower participation in advance care planning discussions. In a kidney-specific context, Langham emphasized that health literacy is a critical determinant of individuals’ ability to comprehend disease trajectories, navigate complex treatment options, and engage in informed and proactive care planning across the kidney disease continuum⁴⁰. Furthermore, a scoping review by Shah demonstrated that individuals with lower health literacy frequently experience difficulties initiating advance care planning conversations, largely due to challenges in processing complex medical information and navigating healthcare systems⁴¹.

For individuals receiving peritoneal dialysis, the role of health literacy may be particularly salient given the home-based and self-managed nature of treatment. The ability to independently perform dialysis procedures, recognize complications, and communicate effectively with healthcare professionals may influence not only day-to-day treatment management but also readiness to engage in future-oriented care planning⁴². Therefore, although not directly assessed, health literacy may function as an unmeasured but meaningful factor shaping ACP readiness in this population. Future studies should incorporate validated health literacy measures to further clarify its role in ACP engagement among individuals receiving PD.

Impact of death anxiety on ACP readiness

Death anxiety was a significant negative predictor of ACP readiness (β = −0.20). From a theoretical perspective, the observed negative association between death anxiety and ACP readiness is consistent with established psychological models of fear-based avoidance⁴³. According to terror management theory and avoidance-oriented coping frameworks, heightened fear of death may activate defensive mechanisms such as denial, emotional suppression, or experiential avoidance, which serve to reduce immediate psychological distress but simultaneously inhibit engagement with future-oriented planning behaviors.

Advance care planning inherently requires individuals to confront mortality, anticipate future health deterioration, and reflect on end-of-life preferences⁴⁴. For patients with elevated death anxiety, such cognitive and emotional demands may be perceived as threatening, leading to avoidance of ACP-related discussions despite their potential long-term benefits. In this context, higher levels of death anxiety were negatively associated with ACP readiness, suggesting that death-related emotional distress may be linked to reduced engagement in proactive decision-making related to future care.

This interpretation is further supported by prior research indicating that individuals with high levels of death anxiety are more likely to engage in short-term emotion regulation strategies at the expense of long-term planning, particularly in populations facing chronic or life-limiting illnesses⁴⁵. Therefore, addressing death-related fear through supportive communication or psychosocial interventions may be a prerequisite for enhancing ACP readiness among individuals receiving PD.

Quantitatively, each one-point increase in death anxiety score was associated with an approximate 1.03-point decrease in ACP readiness. This finding indicates that emotional responses to death constitute a substantial psychological barrier to ACP engagement among individuals receiving PD.

The magnitude of this effect underscores the importance of addressing emotional distress in ACP-related interventions. Patients experiencing heightened death anxiety may engage in avoidance or denial behaviors, limiting their willingness to contemplate future care decisions. Similar negative associations between death anxiety and ACP engagement have been reported in kidney failure populations receiving dialysis and in oncology populations^34,46, suggesting that emotional regulation may represent a critical leverage point for improving ACP readiness.

Role of nephrology nursing workforce and training in ACP implementation

Beyond individual-level determinants, the successful implementation of advance care planning in kidney care settings is highly dependent on the preparedness and confidence of the nephrology nursing workforce. Nephrology nurses are often the healthcare professionals with the most sustained and frequent contact with individuals receiving peritoneal dialysis, placing them in a pivotal position to initiate, facilitate, and normalize ACP discussions across the disease trajectory.

However, initiating conversations about future care preferences, prognosis, and end-of-life issues can be challenging for both individuals and healthcare professionals. Without adequate training, nurses may experience uncertainty, discomfort, or fear of causing distress, which may result in delayed or avoided ACP discussions. Evidence suggests that structured training programs focusing on communication skills, ethical decision-making, and culturally sensitive approaches can enhance nurses’ confidence and competence in engaging in ACP conversations³⁶.

In the context of peritoneal dialysis, where care is largely home-based and relies heavily on self-management and family involvement, nephrology nurses play a critical role in supporting not only clinical care but also anticipatory decision-making. Strengthening ACP-related training for nephrology nurses may be relevant to the implementation of ACP, although its direct association with ACP readiness cannot be inferred from the present cross-sectional data.

Limitations

Several limitations of this study should be acknowledged. First, a convenience sampling strategy was used, and participants were recruited exclusively from two tertiary hospitals in Sichuan Province. Although this approach was pragmatic given the clinical context and the limited number of stable individuals receiving peritoneal dialysis (PD), it may have introduced selection bias. In particular, individuals receiving care in tertiary hospitals are more likely to reside in urban areas, have better access to specialized healthcare resources, and demonstrate higher levels of treatment adherence and engagement with healthcare services. As a result, the study sample may overrepresent more compliant or health-engaged patients, potentially leading to an overestimation of advance care planning (ACP) readiness and limiting the external validity of the findings. Caution is therefore warranted when generalizing the results to PD populations in rural areas, primary care settings, or regions with fewer healthcare resources.

Second, the cross-sectional design of this study precludes causal inference regarding the relationships between ACP readiness and its associated factors. Although significant associations were identified between ACP readiness and clinical and psychosocial variables, the temporal direction and underlying causal mechanisms cannot be determined. Longitudinal studies are needed to clarify how ACP readiness evolves over time and how changes in clinical burden or psychosocial resources influence readiness.

Third, although multiple demographic, clinical, and psychosocial variables were included in the regression model, residual confounding from unmeasured factors cannot be excluded. Variables such as health literacy, quality of patient–clinician communication, spiritual beliefs, prior experiences with end-of-life care, and culturally shaped attitudes toward death were not directly assessed and may have influenced ACP readiness.

Fourth, all data were collected using self-report questionnaires, which may be subject to recall bias and social desirability bias, particularly given the sensitive nature of advance care planning and death-related topics within the Chinese cultural context. Despite assurances of confidentiality, participants may have underreported death-related anxiety or overreported their readiness to engage in ACP.

Finally, although the measurement instruments used in this study demonstrated acceptable internal consistency reliability, they were not specifically developed or psychometrically validated for peritoneal dialysis populations. No confirmatory factor analysis (CFA) was conducted within the present sample, and the factor structures and CFA indices cited for the ACPRS, CT-DAS, and SSRS were derived from previous validation studies conducted in broader Chinese chronic disease populations. Consequently, the construct validity and measurement equivalence of these instruments in individuals receiving PD cannot be fully established, which represents an important methodological limitation. Future studies should conduct PD-specific psychometric validation, including factor structure testing and measurement invariance analysis, to strengthen the assessment of ACP readiness and related psychosocial constructs in this population.

Conclusion

This study demonstrates that advance care planning (ACP) readiness among individuals receiving peritoneal dialysis (PD) in China remains at a moderately low level, indicating limited preparedness for future medical decision-making. After applying established cutoff criteria, all ACPRS subdimensions—including attitude, belief, and motivation—were classified as moderately low, suggesting that insufficient readiness reflects a multidimensional pattern rather than deficits in isolated domains.

Multivariate regression analysis identified dialysis duration, number of comorbidities, social support, and death anxiety as factors associated with ACP readiness. Longer dialysis duration and greater comorbidity burden were positively associated with readiness, possibly reflecting increased illness awareness and perceived relevance of future care planning. In contrast, death anxiety showed a significant negative association with ACP readiness, indicating that emotional responses to death may hinder engagement in ACP-related considerations. Social support was positively associated with readiness, underscoring the potential role of interpersonal and professional support in facilitating ACP engagement.

These findings suggest several potential directions for future research and practice. Individuals receiving PD with longer dialysis duration or multiple comorbidities may represent groups in whom ACP discussions could be more readily initiated. Approaches that aim to strengthen perceived social support or address death-related anxiety may be considered as components of ACP-promoting strategies. However, given the observational nature of this study, such implications should be interpreted cautiously, and the feasibility and effectiveness of specific interventions require further validation through longitudinal and interventional research.

Overall, this study contributes to a better understanding of ACP readiness and its associated factors among individuals receiving PD within the sociocultural context of China. Future studies are warranted to clarify causal pathways and to evaluate targeted, theory-informed interventions that integrate clinical characteristics and psychosocial processes into routine PD care.

Author contributions

T.L. (Ting Luo): Methodology, Validation, Resources, Data curation, Investigation, Visualization, Formal analysis, Writing – original draft.Q.J. (Qian Jiang): Methodology, Validation, Resources, Data curation, Investigation, Visualization, Formal analysis, Writing – original draft.P.W. (Ping Wei): Validation, Investigation, Writing – review & editing.Q.Y. (Qian Yang): Validation, Investigation, Writing – review & editing, Funding acquisition.R.Z. (Rong Zeng): Validation, Investigation, Writing – review & editing.L.W. (Liping Wang): Supervision, Resources, Formal analysis.X.L. (Xiao xia Lin): Conceptualization, Resources.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request. Data are located in controlled access data storage at Chengdu Medical College.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was conducted in accordance with the principles of the Declaration of Helsinki. This study was approved by the Medical Ethics Committee of Chengdu Medical College (registration number: Cheng Yi Lun Shen 2024 NO.107), and all participants signed the informed consent form.