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BMC Palliat Care. 2019 Nov 5;18(1):95. doi: 10.1186/s12904-019-0482-x.

Action research study on advance care planning for residents and their families in the long-term care facility.

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Department of Nursing, Tzu Chi University of Science and Technology, No. 880, Section 2, Chien-kuo Road, Hualien City, 97005, Taiwan, Republic of China.
Department of Nursing, Chang Gung University of Science and Technology, No. 261, Wenhua 1st Road, Guishan District, Taoyuan City, 33303, Taiwan, Republic of China.
Mackay Junior College of Medicine, Nursing and Management, No. 92, Shengjing Road, Beitou District, Taipei City, 11260, Taiwan, Republic of China.
Department of Family Medicine, National Taiwan University, No. 1 Chang-de Street, Zhong Zheng District, Taipei, 10048, Taiwan, Republic of China.
Department of Nursing, National Taiwan University, No. 1, Sec. 1, Jen-Ai Road, Zhong Zheng District, Taipei City, 10048, Taiwan, Republic of China.



Research in Taiwan has indicated that advance care planning is rarely undertaken in long-term care facilities. The purpose of this study was to develop an advance care planning interview guideline and care model to facilitate the process of advance care planning for residents and their families in long-term care facilities.


This study follows an action research design. Cycles of planning, action, observation, and reflection were planned and modified based on the results of interviews with residents and their families as well as meetings with staff. To establish the interview guideline and care model through this action research study, residents and their families were interviewed separately. The researcher subsequently held meetings with staff members to evaluate the results and identify problems during each advance care planning process. This information was synthesised and used to modify the care model for implementation with the next resident-family pair. This process was performed a total of ten times.


This study included residents (N = 10), their families (N = 20), and medical staff (N = 4) at a long-term care facility. The interviews and meetings were audio recorded, transcribed, and subjected to a simple thematic analysis together with the field notes and reflection logs. Four themes emerged from the data related to: opening the conversation with the interview guidelines about the life story of residents; continuing life stories to the quality of remaining years of the residents; gradually changing the topic to the end-of-life care issues; and concluding the conversation by explaining the content of advance directives and hospice care.


The advance care planning care model was implemented following logical thinking from a Chinese perspective. This consisted of opening, developing, changing, and concluding through the views of Confucianism, Buddhism, and Taoism. The research findings indicate that the model successfully facilitated the process of advance care planning for residents and their families.


Action research; Advance care planning; Advance directives; Long-term care facility

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