When Advance Care Planning Is Not Yet an Option: Preconditions for Participation and the Relational Work of Nursing

ABSTRACT

Advance care planning (ACP) non‐initiation is commonly attributed to information deficits or low motivation. I argue here that a more fundamental barrier exists: ACP may not yet have become cognitively and relationally available as a meaningful option within a person's everyday horizon. Drawing on a concept‐oriented review of the theoretical and empirical literature, I develop a participatory framework built on four linked preconditions. First, decision readiness describes the pre‐decisional state, in which future care becomes sufficiently thinkable to enter dialogue. Second, the cognitive repertoire reconceptualises ACP learning as the formation of latent resources —values, questions and interpretive frames—that can be activated when life circumstances make future care salient. Third, self‐disclosure highlights that, even when internal readiness exists, participation depends on relational and emotional conditions that make concerns speakable. Fourth, supportive nudging describes the deliberate design of environmental and relational conditions that allow already‐existing concerns to surface without compromising autonomy. Altogether, these preconditions suggest that ACP non‐initiation is better understood as a problem of option accessibility than one of information transfer. This reframing has direct implications for how ACP interventions are designed and evaluated and extends to the broader questions of patient and public participation in future‐oriented care.

1. Introduction

Advance care planning (ACP) has been increasingly framed as a continuous process through which people reflect on and communicate their values, goals and preferences for future care (Rietjens et al. 2017; Sudore et al. 2017). ACP is thus highly relevant to patient‐centred care, shared decision‐making (SDM) and public participation in healthcare. However, initiating ACP in practice remains difficult. Many people recognise that ACP is important, yet postpone, avoid or wait for a crisis before engaging in it (Gao et al. 2024; Suen et al. 2024). I consider this gap between recognition and action, which is widely documented across clinical and community settings and persistent even when ACP programmes are well established, as the central problem of this essay.

A common explanation for the gap is a lack of knowledge: if patients and citizens know more about ACP, they might be more likely to engage in ACP‐related discussions or planning. However, I argue that this assumption is incomplete. Suen et al. (2024) and Zwakman et al. (2018) suggested that ACP‐related dialogues or actions may be inhibited by psychological, structural and educational factors, even if some degree of knowledge or awareness is present. I read this evidence not merely as documenting barriers, but as pointing to a deeper problem: the difficulty lies not only in information deficits but also in whether ACP can actually be thought about, spoken about and treated as one's own concern.

This question is particularly relevant to nursing. Nurses occupy a relational position distinct from that of physicians or social workers: they encounter patients across repeated, often informal moments of care—during routine visits, personal care or quiet intervals between clinical procedures. These encounters create conditions in which the concerns about future care may surface, be suppressed or be gently supported into speech. However, nursing's contribution to ACP has been predominantly framed in terms of documentation support, care coordination or referral. If the difficulty of ACP initiation lies partly in whether ACP becomes available as a thinkable and speakable option, I argue that nursing's role needs to be reconsidered—not only as a facilitator of planning, but as a creator of the conditions under which planning becomes possible.

Recent critiques have intensified the need for this reconceptualisation. Despite decades of research and substantial investment, Morrison et al. (2021) have shown that ACP has not produced goal‐concordant care reliably. I share their concern that the focus on documentation and immediate behavioural outcomes may be misplaced. Sudore et al. (2022) have further noted that ACP encompasses a broader set of processes than documentation alone—a point that, I suggest, has not yet been fully integrated into how nursing's role in ACP is theorised. Jacobsen et al. (2022) proposed a shift from ‘advance care planning’ to ‘serious illness communication’, emphasising preparation for in‐the‐moment decision‐making over advance documentation, while Malhotra (2024) called for ACP to be ‘reimagined and rebranded’ through a framework of ‘Educate, Share, Prepare’ that prioritises ongoing communication over one‐time planning events. I read these critiques as collectively signalling that the field is ready for a more fundamental rethinking of what ACP participation requires.

Although these assessments are important, they are primarily concerned with what ACP should be about and how it should be evaluated. Instead, I ask a different question: under what conditions does ACP become a meaningful option for both patients and citizens in general? Rather than asking only whether people know about ACP or whether an intervention produces immediate behavioural changes, I aim to identify what factors must be in place for ACP to enter a person's cognitive and relational horizon as something they can think about, speak about and act upon. I consider Ocloo and Matthews' (2016) insights that meaningful participation requires options to become visible and personally relevant within participants' cognitive and relational horizons to be directly applicable here: if ACP does not become available as a thinkable and speakable option, participation remains constrained regardless of the formal opportunity structures. To explore this idea, I integrate four linked concepts—decision readiness, cognitive repertoire, self‐disclosure and supportive nudging—as preconditions for meaningful ACP participation.

These concepts have not previously been combined to explain the preconditions for ACP participation. I contend that the contribution of this essay lies not in introducing new concepts but in showing how these ideas, when connected sequentially, reveal a participatory structure that existing ACP frameworks do not currently address. ACP non‐initiation may thus be better understood as a problem of option accessibility rather than a simple failure of information transfer. Moreover, ACP participation may depend on the relational and environmental conditions that allow concerns and preferences to become speakable without compromising autonomy.

I consider that examining these preconditions also requires a shift in how nursing knowledge is applied. ACP is rarely a single clinical event, as it unfolds—or fails to unfold—across the texture of ongoing relationships. This places nurses at a particularly significant juncture: not as gatekeepers of a process, but as the professionals most consistently present at moments when the preconditions for participation are created, missed or foreclosed. Therefore, a framework that addresses these preconditions has direct implications for how nurses understand their role in ACP and how ACP education and practice development are designed.

The contributions of this essay are threefold. First, I reframe ACP non‐initiation as a problem of option accessibility rather than one of information deficit, extending existing critiques to examine the preconditions for patient and public participation. Second, I introduce the cognitive repertoire as a complementary perspective, suggesting that learning should be understood not only in terms of immediate behavioural outcomes but also as generating resources for later engagement. Finally, I link ACP participation to the psychology of self‐disclosure and supportive nudging, highlighting the need to actively create relational and environmental conditions that make options visible and speakable. These contributions create a participatory framework for understanding a layer of ACP difficulty that remains underexplored in both research and practice.

2. Conceptual Approach

This essay draws on concept‐oriented engagement with the relevant theoretical and empirical literature rather than conducting a systematic or scoping review. I reviewed the literature as a way of determining the conditions under which ACP becomes available as a meaningful personal option. I have identified the sources through non‐systematic searches of major bibliographic databases and citation tracking, selected based on their relevance to the psychological, relational and behavioural dimensions of ACP participation.

Through an iterative process of conceptual reflection and synthesis, I brought together four interrelated ideas—decision readiness, cognitive repertoire, self‐disclosure and supportive nudging—to explore how ACP becomes thinkable, speakable and actionable within a person's everyday horizon. I also prioritised the internal coherence of the argument over breadth of literature coverage. I selected sources for their conceptual relevance to the preconditions I was developing, rather than as a representative sample of ACP scholarship. This approach reflects the purpose of a conceptual essay, in which the literature is used to illustrate, extend, refine and occasionally challenge an emerging argument rather than to provide a systematic synthesis of the field.

3. ACP Initiation Difficulty as a Problem of Option Accessibility

I propose that ACP initiation difficulty is best understood as a problem of whether ACP is a meaningful option in everyday life. This perspective goes beyond the assumption that non‐participation merely reflects a lack of awareness. A person may know what ACP is, agree that it is important and still not experience it as relevant to their own current decision‐making horizon. Therefore, I argue that ACP initiation difficulty is not a knowledge problem but an accessibility one; namely, it does not mean that a person lacks information but that ACP has not yet entered the space of things they feel entitled or able to think about and act upon.

I find this interpretation consistent with the empirical studies I draw upon in this essay. For instance, in a systematic review of patient experiences, Zwakman et al. (2018) emphasised the importance of readiness for ACP engagement, arguing that engagement depends not only on information but also on a person's capacity to psychologically confront future care—a finding I read as supporting the distinction between knowing about ACP and being able to engage with it as a personal option. In a subsequent qualitative study of ACP conversations, Zwakman et al. (2021) showed that patients expressed both being and not being ready within the same conversation, with signs of not being ready being especially prominent when future‐oriented topics were raised. I take this to mean that readiness is not a stable trait but a fluctuating condition that depends on topic, relationship and conversational moment (Zwakman et al. 2021). As such, I consider that non‐participation at any given moment may not indicate a settled disposition against ACP, but rather the absence of the conditions under which ACP can become a current topic.

It is well recognised that individuals underestimate future health risks, thereby weakening their anticipatory behaviour. For ACP, I suggest that this helps explain why many people implicitly position ACP as ‘important, but not yet necessary’. This pattern may also be reinforced by the perceived ambiguity of ACP's future‐oriented benefits; that is, because the outcomes of engaging in ACP are diffuse and difficult to specify concretely, the value of initiating it may not become motivationally salient, even when ACP is cognitively understood. In a nationally representative survey, Nouri et al. (2025) found ACP engagement to be associated with specific and contextualised worries about future care rather than diffuse concerns alone, which I interpret as suggesting that ACP becomes more actionable when future care is not merely abstractly acknowledged but concretely imagined.

I argue that this ambiguity is not confined to patients or their families. Even among physicians, the appropriate timing and triggers for ACP initiation remain unclear. I suggest that this reflects the continuing lack of consensus regarding when and how ACP conversations should begin. In a cross‐national survey of Dutch and UK physicians, Van Der Steen et al. (2016) found considerable ambiguity regarding whether ACP should be initiated at the time of dementia diagnosis, with marked variability in consensus that could not be explained by differences in healthcare systems, patient exposure or professional training. I consider Phenwan et al.'s (2020) narrative review to be reinforcing this point, as ‘uncertainty about when to initiate ACP’ was identified as one of the three most frequently cited barriers in dementia literature. More recently, in a mixed‐methods health record study, Tros et al. (2022) showed that the timing GPs considered optimal for ACP initiation was consistently earlier than the timing of ACP conversations actually being recorded, with the discrepancy being particularly pronounced in patients with multimorbidity. All these findings reinforce my central argument that ACP difficulty is not merely a matter of knowledge but rather of when and how ACP becomes recognisable as an actionable option; this problem applies at both the patient and professional levels.

Recent studies on ACP in Japan have further illustrated this phenomenon. Ito et al. (2026) found that 38% of healthcare professionals equated ACP exclusively with decisions to forgo active treatment—a finding I interpret as evidence that, even among professionals, ACP may not be cognitively available in its intended and broader form. This conceptual confusion at the provider level likely compounds the difficulty that patients experienced in recognising ACP as relevant to their own situations.

I propose, on the basis of this evidence, that ACP participation may fail in the pre‐decision stage. Before individuals can participate in ACP, they must first be able to access it cognitively as something that falls within their field of possible action. In this sense, non‐participation may reflect not only exclusion or disinterest but also the absence of a condition in which ACP is available as an option.

I believe these findings have important implications for how patient and public participation is understood. Participation is often discussed in terms of opportunity structures, communication processes and institutional openness (Ocloo and Matthews 2016), but I argue that ACP reveals an additional layer: participation may also depend on whether a future‐oriented topic becomes imaginable enough for a person to recognise it as theirs and to engage with. This resonates with Eldh et al. (2008), in that patients most frequently describe non‐participation not as exclusion from decision‐making but as not being listened to, not being recognised as individuals or not feeling secure enough to express their concerns. Similarly, Abma and Broerse's (2010) work on interactive agenda‐setting demonstrates that meaningful participation requires deliberate preparation—patients do not automatically enter dialogue as equal partners simply because a formal opportunity exists. Building on this, I suggest that participation depends on preconditions that must be actively created, which applies in particular to ACP, where the topic itself may not yet have become available to the concerned persons. Research from a temporal perspective suggests that an individual's orientation towards the future—the capacity to mentally represent and emotionally engage with future states—substantially shapes anticipatory decision‐making and goal‐directed behaviour. I thus conclude that ACP non‐initiation is better understood as a problem of option accessibility than one of information or motivation alone: before participation can occur, ACP must first become available as something a person can think about, speak about and recognise as personally relevant.

4. Decision Readiness as a Precondition for Participation

I propose that a useful way to conceptualise the pre‐decision stage is through decision readiness—a state in which a person can realistically imagine future medical decision‐making and is psychologically prepared to engage in it. This concept is particularly relevant to ACP because, unlike most clinical decisions, it concerns hypothetical future states over immediate choices.

I argue that a person cannot meaningfully articulate values or preferences about future care if those futures remain too abstract, distant or emotionally threatening to contemplate. Sinclair et al. (2024) provided empirical support for this claim: when older adults were presented with hypothetical future care and treatment scenarios, approximately 35%–45% reported clinically significant levels of decisional conflict and higher decisional conflict was significantly associated with lower ACP engagement. I consider this as evidence that readiness is not identical to intention or action; rather, it is a pre‐decisional state in which ACP becomes sufficiently thinkable to be brought into dialogue. This observation, I suggest, parallels the findings of SDM research. Keij et al. (2021) identified multiple elements constituting patient readiness for SDM—including health literacy, self‐awareness and consideration skills—and showed that readiness is further shaped by emotional distress and clinician–patient relationships. I argue that the readiness required for ACP is even more demanding than that required for SDM; whereas SDM anchors the decision in the current clinical situation, ACP requires a person to project themselves into an imagined future that may or may not occur. This makes the formation of readiness more difficult and dependent on the types of experiential and narrative supports that I discuss below.

Zwakman et al. (2018) explicitly identified readiness as central to ACP engagement—a point I consider foundational to this essay. I find Jammal et al.'s (2024) systematic review of qualitative studies on family caregivers of stroke survivors particularly illuminating in this regard: providing care for a seriously ill person reshapes caregivers' perceptions of the future, including a heightened awareness of their own health vulnerability, uncertainty about what lies ahead and the reordering of life priorities. Although this study does not address ACP directly, I interpret this to mean that caregiving experiences can make future health crises and decision‐making situations concretely imaginable rather than abstract. The significance of such indirect pathways lies in the possibility that ACP may become more available not only through direct information about ACP itself but also through the experiences that change how future care is imagined. Indirect pathways to readiness deserve attention because they do not require a person to be ‘ready for ACP’ in advance; instead, they help create the conditions from which readiness can emerge.

Recent reviews further support this perspective. Tan et al. (2024), in a systematic review and meta‐analysis based on the transtheoretical model, found that 26%–72% of participants across studies were in the precontemplation stage, that is, they had not yet begun to consider ACP at all. This wide range indicates that readiness is highly context‐dependent and varies across populations, settings and cultural norms. Gao et al. (2024) reported similar findings for community‐dwelling older adults, noting that, while ACP knowledge was limited across settings, attitudes were generally positive—a gap I interpret as lying in the domain of readiness rather than motivation. In a mixed‐methods systematic review of ACP readiness among older adults with frailty, Fujimoto et al. (2025a) concluded that individual behaviour change models alone are insufficient and that readiness is a dynamic process influenced by family caregivers, professionals and healthcare system factors. I find this conclusion particularly resonant with my argument. In a companion qualitative study conducted in Japan, Fujimoto et al. (2025b) also showed that readiness for ACP in a homecare setting was deeply embedded in the relational and contextual dynamics among older adults, family caregivers and practitioners.

I can thus conclude that decision readiness is shaped not only by information but also by how people encounter illness and vulnerability, whether directly or indirectly. Narrative and experiential approaches matter for precisely this reason. Green and Brock (2000) and Hinyard and Kreuter (2007) have shown that narrative‐based experiences allow people to imaginatively follow another person's situation and emotions, thereby supporting realistic anticipation of future medical contexts without necessarily provoking overwhelming fear—a mechanism I regard as directly relevant to ACP readiness. This effect operates through what Green and Brock (2000) termed narrative transportation—a psychological process in which attention, emotion and imagery are integrated such that the listener or reader becomes cognitively and emotionally immersed in a story, temporarily suspending critical resistance and returning from the narrative world with changed attitudes and beliefs. Yang et al. (2025) have further demonstrated that this mechanism can be effectively deployed in health interventions to reduce stigma and support engagement with difficult topics, reinforcing the case I am building for the role of narrative in making ACP thinkable.

Grossmann and Kross (2014) have shown that people tend to reason in more depth about others' social and interpersonal problems than about their own (i.e., Solomon's paradox), but that self‐distancing can reduce this self–other asymmetry. I find this insight directly applicable to ACP: another person's story may provide reference for thinking about future care through self‐distancing, allowing an individual to consider future decision‐making with greater equanimity by using another person's experience as an intermediary, rather than confronting their own mortality or vulnerability directly. I argue that narrative self‐distancing may thus lower the threshold at which ACP becomes thinkable, thereby supporting participation.

I further suggest that readiness for ACP may be enhanced not only through narrative engagement but also through the experiences of altruistic action and caregiving. As argued above, caring for a seriously ill person can reshape the perceptions towards the future in ways that make future health crises concretely imaginable—a change that I proposed to function as a precondition for ACP engagement. Erikson's (1982) concept of generativity further supports this idea in that acts of supporting and guiding others can facilitate self‐understanding and value clarification. From this perspective, caring for an ill family member or acting as a surrogate decision‐maker may surface personal concerns and priorities regarding one's own future care, even without deliberate reflection on death. Nouri et al. (2025) provided empirical grounding for this claim, showing that people who harbour concrete worries—not only about their own diagnosis but also about whether a surrogate would make the best decisions, whether they could access optimal treatment, or how the caregiving burden might unfold—are more likely to engage in ACP. Because such worries are often directed towards significant others rather than towards oneself, altruistic actions and caregiving experiences may serve as important entry points for personal reflection and action readiness regarding ACP.

I believe that this view resonates with the foundational claims in narrative medicine—a distinct tradition concerned not with the effect of stories on patients directly, but with cultivating narrative competence in clinicians and educators, enabling them to recognise, interpret and respond to patients' illness experiences. Charon (2001) described this competence—the capacity to absorb, interpret and respond to stories—as enabling clinicians to enter and be moved by the narrative world of another's illness. I argue that, in ACP, both receiving others' crisis experiences as narratives and the lived experience of supporting family members through illness may connect abstract knowledge about future care to what it might personally mean for oneself and close ones. As a result, ACP may shift from being ‘a general topic that might be needed one day’ to ‘a more personally available option to consider for oneself and one's loved ones’.

I thus propose that the value of narrative lies in the fact that it does not directly push people towards immediate decision‐making. Rather, it may help reduce the cognitive and emotional distance between present life and future care, making ACP a possible topic for reflection and dialogue. In this sense, narratives support decision readiness, which in turn functions as a precondition for meaningful participation. Decision readiness should be understood not merely as a psychological state but as a precondition resource—one that enables later patient and public participation and can be cultivated through the relational and experiential conditions I have been describing.

5. ACP Learning as the Formation of a Cognitive Repertoire

I propose a distinct way to extend this argument by reconsidering what ACP learning should achieve. Rather than seeing ACP education as the transmission of information or a trigger for immediate behavioural change, I suggest it might be more useful to conceptualise ACP learning as the formation of a cognitive repertoire. Unlike existing ACP education models that evaluate success primarily through immediate behavioural outcomes (e.g., the completion of advance directives or engagement in documented discussions), the cognitive repertoire framework I propose shifts the attention to the preparatory resources that make subsequent engagement possible.

I understand a cognitive repertoire as a set of cognitive resources—including values, questions, interpretive frames and possible lines of dialogue—that may be activated in specific future contexts and relationships. From this perspective, ACP learning is not merely the acquisition of information that can be immediately deployed after an intervention; rather, it involves the creation of a repertoire that becomes available when relevant circumstances arise. I wish to distinguish this concept from knowledge in a narrow informational sense; that is, a repertoire includes not only facts but also dispositions, questions one has learned to ask and ways of framing situations that make certain types of dialogue possible.

The theoretical basis of this proposal lies in several converging strands of learning theory. In a qualitative study of nursing students, Günay and Kılınç (2018) showed that learners may retain theoretical knowledge that does not immediately translate into practice because of anxiety and contextual constraints, a finding I read as directly supporting the idea that the absence of immediate behavioural change does not indicate failed learning. Eraut (2000) further showed that the knowledge acquired in one setting is not simply transferred intact but is re‐situated and re‐integrated when it becomes relevant in another setting. I find Kolb's (1984) experiential learning theory equally pertinent here: learning is conceptualised not as a one‐off movement from instruction to behaviour but as a cycle of experience, reflection, conceptualisation and experimentation. Similarly, Perkins and Salomon (1992) argued that the transfer of learning often depends on mindful abstraction and a deliberate search for connections across contexts rather than instant application.

I thus conclude that learning can be meaningful even when it does not immediately produce observable behaviours. The value of learning, I suggest, may lie precisely in preserving ‘possible lines of thought’ that can later be activated when a person encounters illness, frailty, caregiving or difficult clinical choices. It follows that ACP should not be treated as an exceptional learning domain in which educational success is judged only through instant action.

I return here to narrative medicine, but now in a different register: not as a mechanism through which patients and families encounter stories that make ACP thinkable, but as an educational tradition that cultivates the relational and interpretive capacities of clinicians and students. In a recent scoping review, Palla et al. (2024) confirmed that story‐based education and training in clinical and educational settings consistently developed participants' capacities for empathic listening, reflective interpretation and patient‐centred communication. I consider these cognitive and relational resources to be constituting the type of cognitive repertoire for dialogue on future care that I am arguing for. Notably, the benefits of narrative medicine training were not limited to immediate clinical encounters; rather, as Palla et al. (2024) showed, they contributed to enduring capacities—reflective skills and empathic attitudes—that can be drawn upon in new and unanticipated contexts later. I take this as evidence that the repertoire‐building function of narrative education is not incidental but central to its value.

The cognitive repertoire framework is particularly relevant to the ongoing debate on ACP evaluation. Morrison et al. (2021) criticised ACP for failing to produce measurable improvements in patient outcomes, while Jacobsen et al. (2022) proposed a shift towards serious illness communication that prepares patients for in‐the‐moment decision‐making. I read both critiques as pointing in the same direction and propose the cognitive repertoire framework as a complementary perspective that addresses what they leave implicit. Rather than expecting ACP learning to produce immediate behavioural change, I argue it is more appropriate to assess whether learning generated a usable repertoire that supports future engagement. If ACP learning is evaluated only by whether it produces immediate behavioural change, preparatory learning will appear ineffective by design—not because it failed, but because it is being measured against the wrong outcome. The cognitive repertoire framework reframes this problem: learning may be effective precisely because it creates resources that are not immediately deployed but become available later. I find this argument to be directly aligned with Malhotra's (2024) Educate–Share–Prepare model, which explicitly positions the ‘Educate’ component as foundational preparation rather than direct action.

The idea of ACP learning as a cognitive repertoire is further supported by the evidence of what actually triggers ACP engagement. Research has consistently shown that ACP is rarely initiated by formal education alone and is more often prompted by specific life events—most notably, experiences of illness, caregiving and the death of people close to oneself. Amjad et al. (2014) found that older adults who had experience with end‐of‐life care and decision‐making for others—including having made a medical decision for someone who was dying, or having experienced the death of a loved one who made their end‐of‐life wishes known—demonstrated significantly higher readiness to engage in ACP behaviours. Zhang et al. (2024) showed that exposure to the death of a close person was associated with a twofold increase in the odds of engaging in end‐of‐life conversations with family members. Nouri et al. (2025) further linked ACP engagement to specific, contextualised worries about future care over abstract concerns. I interpret these findings in that ACP knowledge does not require immediate action: if relevant concepts, questions and values have been acquired in advance as part of a cognitive repertoire, they can be activated when a sudden life event renders future care urgent. In this sense, the value of early ACP learning lies precisely in its latency—it creates resources that remain dormant until the situation calls for them.

Myers et al. (2024) proposed the distinction between preparing and deciding, arguing that many patients benefit from communication that supports preparation without immediate decision‐making. I suggest that the cognitive repertoire concept provides the theoretical foundation for this distinction: preparation involves the formation of cognitive resources that enable later decision‐making when the situation demands it. This argument carries clear implications for both patients and the public. Participation in future‐oriented care is often wrongly measured only by immediate behavioural outcomes—whether a discussion occurred, whether a form was completed or whether a decision was documented. I propose an additional evaluative dimension: whether people have acquired the set of ideas, questions and values that allow them to recognise ACP as relevant and engage with it when circumstances change. In this sense, I understand ACP learning as preparation for later action—a process that helps create a repertoire from which future voices and actions can emerge, even when they do not appear immediately. The cognitive repertoire is not merely an educational outcome; it is rather an important participatory resource, one that deserves to be recognised and cultivated as such in both research and practice.

6. Self‐Disclosure, Facilitation and the Supported Voice

ACP depends not only on information and reflection but also on the ability to express values, fears and preferences in dialogue with others. I consider that this dimension of ACP can be illuminated by the psychology of self‐disclosure. As argued in the preceding sections, ACP must first become thinkable (decision readiness), and people need cognitive resources to draw upon it (cognitive repertoire). However, even when both conditions are met, participation may not occur if a person cannot articulate their concerns in a relational context. Self‐disclosure is thus the bridge between internal readiness and external participation.

Sudore et al. (2017) framed ACP as a process of articulating and sharing the values and goals for future care—a framing that, I argue, already implies the conditions of self‐disclosure. Apostol et al. (2025) showed that such disclosure is facilitated by relational safety rather than information alone, while Tamir and Mitchell (2012) demonstrated that self‐disclosure carries intrinsic reward value, even as it may be inhibited by concerns about social evaluation and relational consequences (Apostol et al. 2025). I find Charon's (2001) observation particularly apt here: if a physician fails to create the conditions for narrative engagement, ‘the patient may not tell the whole story, may not voice the most frightening questions, may not feel heard’. Although this observation was originally directed at clinical encounters, I argue that it applies to ACP with equal force: when the conditions for disclosure are absent, the concerns and values most important to the person may remain unvoiced.

ACP is especially demanding in this regard because it concerns death, frailty and potentially conflicting family values. The reluctance to speak should thus not be automatically interpreted as a lack of interest or capacity; rather, it may indicate that the relational and emotional conditions for disclosure have not yet been created. The implications for nursing practice are direct. Because nurses are often present during unguarded moments of care—bathing, medication rounds and late‐night checks—they may be uniquely positioned to notice when a patient is approaching but has not yet crossed the threshold of disclosure. Recognising this threshold and responding in ways that neither push nor foreclose may be one of the most clinically significant yet least formalised aspects of nurses' role in ACP.

Recent research reinforces this perspective. In a scoping review protocol examining self‐disclosure to relational agents for mental health, Sha et al. (2025) identified the fear of stigma and concerns about negative repercussions as key barriers to health‐related disclosure—a finding directly transferable to ACP contexts. Schlozman et al. (2025) developed a framework for understanding mental health disclosure decisions among medical students, showing that anticipated outcomes, preferred recipients and personal priorities shaped whether a person chose to disclose. Although this framework was developed for medical education, I argue that its underlying structure applies equally to ACP: anticipated outcomes may include the fear of distressing family members or being perceived as giving up; preferred recipients may vary between trusted physicians, spouses or adult children, and personal priorities may include protecting relationships over asserting one's wishes. I take these as evidence that ACP disclosures, similar to other forms of health‐related disclosure, are shaped by relational and contextual conditions rather than by information alone. Reflecting on clinical practice, Avny and Alon (2025) suggested that the willingness to be vulnerable—including on the facilitator's side—is essential for creating the relational conditions under which disclosure becomes possible. I find this insight significant, as it implies that ACP facilitation may require not only professional competence but also a degree of relational openness that goes beyond standard clinical communication.

The implications for patient and public participation are direct. Participation is often discussed as if the voice is already present and simply waiting to be heard, but I suggest that ACP points to something more complex. Sometimes the voice emerges only when timing, relationships, support and prompts make this possible. ACP participation should thus be understood not only as inviting people to express preferences but as actively helping to create the conditions under which those preferences can emerge and become speakable.

This interpretation is consistent with the broader patient participation literature. For example, Ito et al. (2026) showed that patients most frequently describe non‐participation not as exclusion from decision‐making but as not being listened to, not being recognised as individuals and not feeling secure enough to tell their whole story—a finding I interpret as suggesting that participation may fail first at the level of voice and recognition, even before formal decision‐making structures are reached.

Shifting the burden of responsibility away from the individual is, I argue, one of the most consequential implications of this reframing. If patients or their family members do not immediately articulate their values or wishes, this should not be read as unwillingness. Rather, I propose that it reflects a lack of supported voice—a situation in which a person has concerns, intuitions or priorities but does not yet have the relational and communicative conditions required to express them. From a nursing perspective, this reframing is consequential: it suggests that the nurse's task is not to elicit a decision or complete a document, but to sustain the relational conditions under which a voice can gradually form. Sustaining such conditions requires a different type of professional competence—one that requires attentiveness to timing, sensitivity to silence and the ability to remain present without imposing direction.

7. Supportive Nudging and the Conditions of Option Availability

Because ACP concerns personal values, any discussion of nudging raises ethical concerns that are important to address directly. A conventional understanding of nudging, rooted in Thaler and Sunstein's (2008) account of ‘libertarian paternalism’, suggests that individuals are being subtly steered towards particular choices. I acknowledge that such steering can amount to a form of manipulation that exploits systematic biases in human decision‐making, rather than merely supporting informed choice.

In ACP, this type of steering is particularly problematic because ACP should support autonomy rather than direct people towards predetermined outcomes. A narrower and more defensible interpretation is thus needed—one that I propose treats nudging not as persuasion but as the creation of conditions under which individuals can more easily access and act upon their own concerns.

Festré and Østbye (2025) noted the limitations of uniform deterministic nudges in domains where values and context matter—a point I find directly applicable to ACP. Moreover, in a study of visiting nurses' ACP practices in Japan, Ushikubo and Ishikawa (2025) showed that experienced practitioners relied on context‐sensitive, practice‐based judgements rather than on explicit rules when deciding when and how to initiate ACP conversations. These nurses used cues such as changes in patients' physical condition, shifts in emotional tone during routine visits or moments when family dynamics created openings for dialogue (Ushikubo and Ishikawa 2025). I read their judgements as not mechanical applications of predetermined criteria but as reflections of accumulated practical wisdom in reading psychological readiness, medical status and relational context. I propose that such practice‐based sensitivity represents precisely the form of supportive nudging I am arguing for, one that respects the patient's own pace and concerns.

On this basis, I understand supportive nudging not as determining the content of judgement from outside, but as arranging the environmental conditions in which such context‐sensitive judgement can be more easily activated. In an ethical analysis of nudging, Saghai (2013) argued that such interventions are most defensible when they preserve meaningful choices and support rather than supplant individual deliberation, a criterion I believe the practice‐based approach I have described satisfies. Alsaqqa (2026) also emphasised nudges that work through context and choice architecture while leaving room for informed evaluation and comparison of alternatives. Under this interpretation, I argue that, in ACP, supportive nudging is not about pushing patients or professionals towards a predetermined outcome; rather, it is about enabling the emergence of already existing but not yet fully articulated concerns and preferences, whether on the part of patients, family members or practitioners.

Supportive nudging, understood in this way, connects directly to the arguments developed in the preceding sections. As I previously argued, decision readiness is a precondition for participation; the voice requires relational and emotional support to become speakable, supportive nudging, describes the environmental and relational design through which these preconditions can be actively created. Ito et al. (2026) illustrated this in the Japanese ACP context, showing that conceptual confusion among healthcare professionals regarding the ethical foundations of ACP limits the conditions under which patients could consider ACP as a meaningful process. In a qualitative study of a community‐based palliative care team collaborating across multiple facilities, Tanimoto et al. (2025) identified the specific barriers and facilitators in creating supportive environments for ACP implementation—findings I read as confirming that the conditions for ACP availability must be deliberately constructed rather than assumed. Nudging in ACP is thus best understood not as a separate technique but as an aspect of participation support: the deliberate creation of conditions under which ACP can become available as an option without being imposed.

8. Conclusions

The proposed framework is summarised in Figure 1, which illustrates the four preconditions as a sequential structure through which ACP may become progressively available as a meaningful personal option.

Figure 1.

A participatory framework of preconditions for meaningful advance care planning (ACP). The four preconditions—decision readiness, cognitive repertoire, self‐disclosure and supportive nudging—are sequentially related and mutually reinforcing, through which ACP becomes progressively more thinkable, learnable, speakable and actionable as a personal option. The nursing role operates across all four levels by creating and sustaining the relational and environmental conditions that support participation.

I have hitherto argued that ACP non‐initiation should not be understood only as a problem of information deficits or weak motivation. Rather, I propose it reflects a pre‐decisional condition in which it has not yet become cognitively and relationally available as a meaningful option.

By engaging with recent ACP critiques and reconceptualisations (Jacobsen et al. 2022; Fujimoto et al. 2025a; Malhotra 2024; Morrison et al. 2021), I suggested that decision readiness, cognitive repertoire, self‐disclosure and supportive nudging together describe the preconditions under which patient and public ACP participation can occur. ACP interventions may thus need to be judged not only by whether they produce immediate behaviours but also by whether they make ACP more thinkable, speakable and personally available as an option. For nursing, this reframing carries particular weight. If ACP participation depends on preconditions that must be actively created, nurses—as the professionals most consistently present across the relational texture of care—are thus not peripheral to this process but central to it. This does not require nurses to initiate formal ACP conversations; instead, it requires them to recognise and sustain the conditions under which such conversations can eventually become possible.

I suggest this perspective has value beyond ACP. In many future‐oriented areas of care—including chronic disease management, genetic counselling and long‐term care planning—participation depends not only on being informed but also on being prepared to recognise an issue as one's own and speak about it. Comparable insights have emerged in the patient participation literature as well. For instance, Eldh et al. (2008) demonstrated that patients require dedicated consultation and empowerment before they can engage as equal partners in a dialogue with professionals, and that the social conditions necessary for meaningful participation must be deliberately created rather than assumed to be already in place. I read ACP as offering a clear case of this broader problem, especially in contexts where family‐centred decision‐making and relational norms shape how and when future care can be discussed (Ito et al. 2026; Mori et al. 2025; Yang et al. 2025).

I thus conclude that ACP participation should not be judged solely by immediate documentation or behaviours, but by whether individuals are helped to recognise ACP as a meaningful option that can later be voiced and acted upon.

However, more research is needed to operationalise and empirically test these preconditions, and I wish to suggest several directions. Option accessibility can be assessed through vignette‐based measures that examine whether individuals can identify ACP as relevant to a described scenario, rather than simply knowing what ACP is. Decision readiness can be tracked longitudinally before and after ACP interventions using instruments that capture not only intention but also the capacity to imagine and articulate future care concerns. Cognitive repertoire formation can be evaluated by examining whether participants, after an educational intervention, generate new questions or framing strategies in follow‐up interviews—even in the absence of documented ACP behaviours. These approaches allow researchers to assess whether ACP interventions create preconditions for subsequent participation, rather than measuring only whether participation occurs immediately.

Developing and testing such measures also requires a closer collaboration between nursing researchers and those working in decision science, health communication and palliative care. The preconditions I have identified here—readiness, repertoire, disclosure and nudging—are not exclusively nursing concepts, but their practical realisation depends substantially on the relational work that nursing makes possible. Advancing this agenda is thus not only a matter of improving ACP outcomes but of clarifying what nursing contributes to participation in future‐oriented care—a contribution that I believe deserves far greater recognition than it currently receives.

Funding

The author has nothing to report.

Ethics Statement

This article is a conceptual essay based on the analysis and interpretation of published literature. It did not involve human participants, human data or human tissue; therefore, ethical approval was not required.

Conflicts of Interest

The author declares no conflicts of interest.

Artificial Intelligence Statement

Artificial intelligence (AI) tools were used during the preparation of this manuscript to assist with literature organisation, structural refinement and drafting support. All content was critically reviewed, revised and approved by the author, who takes full responsibility for the accuracy and integrity of the work.

Data Availability Statement

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.