Journal of Shanghai Jiao Tong University (Medical Science) ›› 2024, Vol. 44 ›› Issue (4): 482-493.doi: 10.3969/j.issn.1674-8115.2024.04.009
• Evidence-based medicine • Previous Articles
FU Yiling(), WU Qian, LUO Xiaoqing, WU Aihong, XIA Xuelan, ZHENG Min()
Received:
2023-11-01
Accepted:
2024-02-06
Online:
2024-04-28
Published:
2024-04-28
Contact:
ZHENG Min
E-mail:1715757154@qq.com;1287285766@qq.com
CLC Number:
FU Yiling, WU Qian, LUO Xiaoqing, WU Aihong, XIA Xuelan, ZHENG Min. Factors influencing advance care planning engagement behavior in patients with advanced cancer: a systematic review[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2024, 44(4): 482-493.
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URL: https://xuebao.shsmu.edu.cn/EN/10.3969/j.issn.1674-8115.2024.04.009
Step | Strategy |
---|---|
#1 | "advance care planning" [MeSH Terms] |
#2 | "advance care planning" [Title/Abstract] OR "advance directives" [Title/Abstract] OR "living wills" [Title/Abstract]) OR "medical power of attorney" [Title/Abstract] |
#3 | #1 OR #2 |
#4 | "terminal" [Title/Abstract] OR "advanced" [Title/Abstract] OR "end-stage" [Title/Abstract] OR "end-of-life" [Title/Abstract] |
#5 | "neoplasms" [MeSH Terms] |
#6 | "neoplasms" [Title/Abstract] OR "cancer"[Title/Abstract] OR "tumor" [Title/Abstract] OR "oncology" [Title/Abstract] OR "malignancy" [Title/Abstract] |
#7 | #5 OR #6 |
#8 | #4 AND #7 |
#9 | #3 AND #8 |
Tab 1 Searching strategy for searching in PubMed
Step | Strategy |
---|---|
#1 | "advance care planning" [MeSH Terms] |
#2 | "advance care planning" [Title/Abstract] OR "advance directives" [Title/Abstract] OR "living wills" [Title/Abstract]) OR "medical power of attorney" [Title/Abstract] |
#3 | #1 OR #2 |
#4 | "terminal" [Title/Abstract] OR "advanced" [Title/Abstract] OR "end-stage" [Title/Abstract] OR "end-of-life" [Title/Abstract] |
#5 | "neoplasms" [MeSH Terms] |
#6 | "neoplasms" [Title/Abstract] OR "cancer"[Title/Abstract] OR "tumor" [Title/Abstract] OR "oncology" [Title/Abstract] OR "malignancy" [Title/Abstract] |
#7 | #5 OR #6 |
#8 | #4 AND #7 |
#9 | #3 AND #8 |
Author | Year | Area | Design | Research method | Sample size | Influencing factor | Quality rating |
---|---|---|---|---|---|---|---|
QU X L, et al | 2020 | Beijing, China | Qualitative study | Phenomenological study | 17 | Ⅰ: ①② | 80% |
BAR-SELA G, et al | 2021 | Israel | Mixed studies | Phenomenological study Questionnaire investigation | 109 | Ⅰ: ①②⑧⑨⑩⑪ Ⅱ: ⑥⑦ | QN: 73% QL: 80% |
WANG Y X, et al | 2019 | Hefei, China | Cross-sectional study | Questionnaire investigation | 520 | Ⅰ: ⑧⑨ Ⅱ: ④⑤⑥⑦⑫ ⑭⑮ | 64% |
WANG L, et al | 2021 | Xi'an, China | Cross-sectional study | Questionnaire investigation | 72 | Ⅱ: ③⑤⑭⑯17 Ⅲ: 18 | 91% |
YAN C X, et al | 2022 | Tianjin, China | Cross-sectional study | Questionnaire investigation | 206 | Ⅰ: ① Ⅲ: ②④⑭ | 86% |
CHEN Y Z, et al | 2022 | Guangzhou, China | Cross-sectional study | Questionnaire investigation | 120 | Ⅲ: ③④⑪19 | 86% |
TANG S T, et al | 2014 | Taiwan, China | Cross-sectional study | Questionnaire investigation | 2 450 | Ⅲ: ⑭2021 | 86% |
WONG S Y, et al | 2012 | Hong Kong, China | Cohort study | Questionnaire investigation | 191 | Ⅲ: 20 Ⅳ: ⑩ | 77% |
HOU X T, et al | 2021 | Beijing, China | Cross-sectional study | Questionnaire investigation | 264 | Ⅲ: ⑤⑥⑫⑬ | 73% |
KIERNER K A, et al | 2010 | Austria | Cohort study | Questionnaire investigation | 108 | Ⅱ: 22 | 64% |
RODENBACH R A, et al | 2021 | America | Cross-sectional study | Questionnaire investigation | 672 | Ⅲ: 19 | 86% |
GARRIDO M M, et al | 2014 | America | Cross-sectional study | Questionnaire investigation | 606 | Ⅲ: 23 | 82% |
NILSSON M E, et al | 2009 | America | Cohort study | Questionnaire investigation | 668 | Ⅲ: 24 | 86% |
TRUE G, et al | 2005 | America | Longitudinal study | Questionnaire investigation | 68 | Ⅲ: ④23 | 73% |
YOO S H, et al | 2020 | South Korea | Cohort study | Questionnaire investigation | 150 | Ⅰ: 25 Ⅳ: 20 | 86% |
BROWN A J, et al | 2016 | America | Cross-sectional study | Questionnaire investigation | 110 | Ⅲ: ③⑥1926 | 77% |
ZHU M L, et al | 2019 | Zunyi, China | Cross-sectional study | Questionnaire investigation | 90 | Ⅱ: ③⑯ | 59% |
WANG Y L | 2021 | Shandong, China | Cross-sectional study | Questionnaire investigation | 145 | Ⅲ: ⑬⑭19 | 91% |
SHEN M J, et al | 2018 | America | Cohort study | Questionnaire investigation | 279 | Ⅲ: 20 | 77% |
SHEN M J, et al | 2020 | America | Qualitative study | Phenomenological study | 20 | Ⅰ: ④⑩⑪1823 | 55% |
JIA Z M, et al | 2022 | America | Qualitative study | Phenomenological study | 21 | Ⅰ: ②⑪27 | 90% |
Tab 2 Characteristics of the included literature
Author | Year | Area | Design | Research method | Sample size | Influencing factor | Quality rating |
---|---|---|---|---|---|---|---|
QU X L, et al | 2020 | Beijing, China | Qualitative study | Phenomenological study | 17 | Ⅰ: ①② | 80% |
BAR-SELA G, et al | 2021 | Israel | Mixed studies | Phenomenological study Questionnaire investigation | 109 | Ⅰ: ①②⑧⑨⑩⑪ Ⅱ: ⑥⑦ | QN: 73% QL: 80% |
WANG Y X, et al | 2019 | Hefei, China | Cross-sectional study | Questionnaire investigation | 520 | Ⅰ: ⑧⑨ Ⅱ: ④⑤⑥⑦⑫ ⑭⑮ | 64% |
WANG L, et al | 2021 | Xi'an, China | Cross-sectional study | Questionnaire investigation | 72 | Ⅱ: ③⑤⑭⑯17 Ⅲ: 18 | 91% |
YAN C X, et al | 2022 | Tianjin, China | Cross-sectional study | Questionnaire investigation | 206 | Ⅰ: ① Ⅲ: ②④⑭ | 86% |
CHEN Y Z, et al | 2022 | Guangzhou, China | Cross-sectional study | Questionnaire investigation | 120 | Ⅲ: ③④⑪19 | 86% |
TANG S T, et al | 2014 | Taiwan, China | Cross-sectional study | Questionnaire investigation | 2 450 | Ⅲ: ⑭2021 | 86% |
WONG S Y, et al | 2012 | Hong Kong, China | Cohort study | Questionnaire investigation | 191 | Ⅲ: 20 Ⅳ: ⑩ | 77% |
HOU X T, et al | 2021 | Beijing, China | Cross-sectional study | Questionnaire investigation | 264 | Ⅲ: ⑤⑥⑫⑬ | 73% |
KIERNER K A, et al | 2010 | Austria | Cohort study | Questionnaire investigation | 108 | Ⅱ: 22 | 64% |
RODENBACH R A, et al | 2021 | America | Cross-sectional study | Questionnaire investigation | 672 | Ⅲ: 19 | 86% |
GARRIDO M M, et al | 2014 | America | Cross-sectional study | Questionnaire investigation | 606 | Ⅲ: 23 | 82% |
NILSSON M E, et al | 2009 | America | Cohort study | Questionnaire investigation | 668 | Ⅲ: 24 | 86% |
TRUE G, et al | 2005 | America | Longitudinal study | Questionnaire investigation | 68 | Ⅲ: ④23 | 73% |
YOO S H, et al | 2020 | South Korea | Cohort study | Questionnaire investigation | 150 | Ⅰ: 25 Ⅳ: 20 | 86% |
BROWN A J, et al | 2016 | America | Cross-sectional study | Questionnaire investigation | 110 | Ⅲ: ③⑥1926 | 77% |
ZHU M L, et al | 2019 | Zunyi, China | Cross-sectional study | Questionnaire investigation | 90 | Ⅱ: ③⑯ | 59% |
WANG Y L | 2021 | Shandong, China | Cross-sectional study | Questionnaire investigation | 145 | Ⅲ: ⑬⑭19 | 91% |
SHEN M J, et al | 2018 | America | Cohort study | Questionnaire investigation | 279 | Ⅲ: 20 | 77% |
SHEN M J, et al | 2020 | America | Qualitative study | Phenomenological study | 20 | Ⅰ: ④⑩⑪1823 | 55% |
JIA Z M, et al | 2022 | America | Qualitative study | Phenomenological study | 21 | Ⅰ: ②⑪27 | 90% |
COM-B component | TDF | Original definition | Application of TDF to the connotation of ACP engagement behavior in patients with advanced cancer |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | An awareness of the existence of something | Understanding and being familiar with ACP-related knowledge |
Memory, attention and decision processes | The ability to retain information, selectively focus on aspects of the environment and choose between two or more alternatives | Ability to remember, focus, and select ACP | |
Behavioural regulation | Anything aiming at managing or changing objectively observed or measured actions | Using healthy behaviors to manage emotions and pursue goals | |
Physical capability | Skills | An ability or proficiency acquired through practice | Acquiring the ability or skill to engage in ACP through practice, including physiological and cognitive skills |
Opportunity | |||
Social opportunity | Social influences | Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors | The process of social activities that enable individuals to change their cognition and behavior about ACP |
Physical opportunity | Environmental context and resources | Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior | Personal conditions and environments that influence ACP engagement |
Motivation | |||
Reflective motivation | Beliefs about capabilities | Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use | Believing that individuals have enough knowledge about ACP and can participate in ACP discussions |
Goals | Mental representations of outcomes or end states that an individual wants to achieve | The psychological outcomes that individuals want to achieve | |
Intentions | A conscious decision to perform a behavior or a resolve to act in a certain way | Identifying the skills that are needed to engage in ACP | |
Beliefs about consequences | Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation | The degree to which the individuals accept the facts or believe that ACP's involvement in the behavior will lead to specific results | |
Automatic motivation | Social/professional role and identity | A coherent set of behaviors and displayed personal qualities of an individual in a social or work setting | Self-perception based on social or professional identity |
Optimism | The confidence that things will happen for the best or that desired goals will be attained | Confidence that the desired goal will be achieved | |
Reinforcement | Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus | Promoting and strengthening support for ACP participation | |
Emotion | A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | A mental state or emotional response that is determined by an individual's environment |
Tab 3 Connotation of the COM-B model in the ACP engagement behavior of advanced cancer patients
COM-B component | TDF | Original definition | Application of TDF to the connotation of ACP engagement behavior in patients with advanced cancer |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | An awareness of the existence of something | Understanding and being familiar with ACP-related knowledge |
Memory, attention and decision processes | The ability to retain information, selectively focus on aspects of the environment and choose between two or more alternatives | Ability to remember, focus, and select ACP | |
Behavioural regulation | Anything aiming at managing or changing objectively observed or measured actions | Using healthy behaviors to manage emotions and pursue goals | |
Physical capability | Skills | An ability or proficiency acquired through practice | Acquiring the ability or skill to engage in ACP through practice, including physiological and cognitive skills |
Opportunity | |||
Social opportunity | Social influences | Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors | The process of social activities that enable individuals to change their cognition and behavior about ACP |
Physical opportunity | Environmental context and resources | Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior | Personal conditions and environments that influence ACP engagement |
Motivation | |||
Reflective motivation | Beliefs about capabilities | Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use | Believing that individuals have enough knowledge about ACP and can participate in ACP discussions |
Goals | Mental representations of outcomes or end states that an individual wants to achieve | The psychological outcomes that individuals want to achieve | |
Intentions | A conscious decision to perform a behavior or a resolve to act in a certain way | Identifying the skills that are needed to engage in ACP | |
Beliefs about consequences | Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation | The degree to which the individuals accept the facts or believe that ACP's involvement in the behavior will lead to specific results | |
Automatic motivation | Social/professional role and identity | A coherent set of behaviors and displayed personal qualities of an individual in a social or work setting | Self-perception based on social or professional identity |
Optimism | The confidence that things will happen for the best or that desired goals will be attained | Confidence that the desired goal will be achieved | |
Reinforcement | Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus | Promoting and strengthening support for ACP participation | |
Emotion | A complex reaction pattern, involving experiential, behavioural, and physiological elements, by which the individual attempts to deal with a personally significant matter or event | A mental state or emotional response that is determined by an individual's environment |
COM-B | TDF | Influencing factor | Specific description |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | Knowledge of ACP | →Getting more information about ACP can help patients to understand its significance[ →Patients do not know, do not understand or misunderstand the related concepts of ACP[ |
Education level | →Cultural education can help patients engage in discussion APC[ | ||
Behavioural regulation | Prior experience | →Patients with disease experience are more likely to discuss ACP[ | |
Physical capability | Skills | Cancer site | →Lung cancer patients are more likely to complete advanced directives/Durable Power of Attorney (DPOA) than brain cancer patients[ |
Opportunity | |||
Social opportunity | Social influences | Race/ethnicity | →Hispanic patients prefer a family-centered, physician-informed approach to discussing ACP with consideration and incorporation of their religious medical beliefs about end-of-life care[ |
Religious belief | →Overly optimistic religious beliefs will affect patients' discussion about ACP[ | ||
Family support | →Patients hope to have open communication with family members[ →Involving family in conversations about end-of-life care can help Latinos to communicate[ →No close relatives agree to take responsibility for preventing patients from engaging in ACP[ →No close relatives can be trusted for preventing patients from engaging in ACP[ | ||
Doctor-patient relationship | →Patients prefer for the trusted doctors to initiate ACP conversations[ →Patients hope to have open communication with physician[ →Patients' preconceived notions of clinicians' professional responsibility may hinder public discussion of future health care goals and values[ | ||
Social support | →Providing culturally counseling services and educational materials can help patients learn how to communicate information about ACP[ | ||
Acculturation | →A key regulator of how patients view ACP is their cultural adaptation to local norms of care, behavior, and communication[ | ||
Physical opportunity | Environmental context and resources | Place of living | →Living in rural areas has a positive impact on patients' willingness to participate in ACP[ |
Motivation | |||
Reflective motivation | Intentions | ACP attitude | →Uncertainty about the timing of patients' engagement in ACP[ →Patients believe that engagement in ACP increases negative emotions[ →Patients question whether ACP itself can be carried out smoothly[ →Patients' belief in an uncertain future may hinder public discussion of future health care goals and values[ |
Goals | ACP belief | →Patients hope to make the best medical decisions and avoid unnecessary medical measures[ | |
Beliefs about capabilities | ACP motivation | →Having the opportunity to discuss disease information openly with families and doctors will increase patients' willingness to engage in ACP[ |
Tab 4 Integration results of qualitative study of influencing factors
COM-B | TDF | Influencing factor | Specific description |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | Knowledge of ACP | →Getting more information about ACP can help patients to understand its significance[ →Patients do not know, do not understand or misunderstand the related concepts of ACP[ |
Education level | →Cultural education can help patients engage in discussion APC[ | ||
Behavioural regulation | Prior experience | →Patients with disease experience are more likely to discuss ACP[ | |
Physical capability | Skills | Cancer site | →Lung cancer patients are more likely to complete advanced directives/Durable Power of Attorney (DPOA) than brain cancer patients[ |
Opportunity | |||
Social opportunity | Social influences | Race/ethnicity | →Hispanic patients prefer a family-centered, physician-informed approach to discussing ACP with consideration and incorporation of their religious medical beliefs about end-of-life care[ |
Religious belief | →Overly optimistic religious beliefs will affect patients' discussion about ACP[ | ||
Family support | →Patients hope to have open communication with family members[ →Involving family in conversations about end-of-life care can help Latinos to communicate[ →No close relatives agree to take responsibility for preventing patients from engaging in ACP[ →No close relatives can be trusted for preventing patients from engaging in ACP[ | ||
Doctor-patient relationship | →Patients prefer for the trusted doctors to initiate ACP conversations[ →Patients hope to have open communication with physician[ →Patients' preconceived notions of clinicians' professional responsibility may hinder public discussion of future health care goals and values[ | ||
Social support | →Providing culturally counseling services and educational materials can help patients learn how to communicate information about ACP[ | ||
Acculturation | →A key regulator of how patients view ACP is their cultural adaptation to local norms of care, behavior, and communication[ | ||
Physical opportunity | Environmental context and resources | Place of living | →Living in rural areas has a positive impact on patients' willingness to participate in ACP[ |
Motivation | |||
Reflective motivation | Intentions | ACP attitude | →Uncertainty about the timing of patients' engagement in ACP[ →Patients believe that engagement in ACP increases negative emotions[ →Patients question whether ACP itself can be carried out smoothly[ →Patients' belief in an uncertain future may hinder public discussion of future health care goals and values[ |
Goals | ACP belief | →Patients hope to make the best medical decisions and avoid unnecessary medical measures[ | |
Beliefs about capabilities | ACP motivation | →Having the opportunity to discuss disease information openly with families and doctors will increase patients' willingness to engage in ACP[ |
COM-B | TDF | Influencing factor | Specific description |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | Knowledge of ACP | →The percentage of patients willing to engage in ACP increased after understanding the concept, process, and importance of advance directive[ |
Behavioural regulation | Knowledge of the time of disease diagnosis | →Patients who know about the diagnosis of the disease for longer are more likely to engage in ACP[ | |
Subjective life expectancy | →Patients who are expected to live only a few months are less likely to prefer aggressive treatment[ | ||
Physical capability | Skills | Disease symptom burden | →The greater the burden of symptoms, the less likely patients are to sign advance directives or health care powers of attorney[ |
Opportunity | |||
Social opportunity | Social influences | Family support | →Family members not objecting is an important factor in discussing ACP[ |
Social support | →Patients with higher social support are more willing to engage in ACP[ | ||
Doctor-patient relationship | →Poor doctor-patient relationship leads to low acceptance of ACP[ | ||
Dependent children | →Patients with dependent children are more likely to prefer aggressive treatment and less likely to engage in ACP[ | ||
Physical opportunity | Environmental context and resources | Housing type | →Patients without private housing are more willing to engage in ACP[ |
Hospice service center | →Whether or not to establish a hospice service center is a factor influencing whether or not patients choose to participate in ACP[ | ||
Motivation | |||
Reflective motivation | Intentions | ACP attitude | →The sense of life meaning is the main factor influencing patients' attitude towards ACP[ |
Goals | ACP belief | →Patients want to ensure a comfortable end-of-life and avoid pain[ | |
Beliefs about capabilities | ACP motivation | →The reason that hinders patients from engaging in ACP is that patients think that their relatives can make decisions for them or that their wishes may change in the future[ | |
Automatic motivation | Emotion | Anxiety and depression | →Patients who participated in ACP had significantly higher anxiety and depression scores than those who did not participate in ACP[ |
Tab 5 Descriptive analysis results of quantitative study
COM-B | TDF | Influencing factor | Specific description |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | Knowledge of ACP | →The percentage of patients willing to engage in ACP increased after understanding the concept, process, and importance of advance directive[ |
Behavioural regulation | Knowledge of the time of disease diagnosis | →Patients who know about the diagnosis of the disease for longer are more likely to engage in ACP[ | |
Subjective life expectancy | →Patients who are expected to live only a few months are less likely to prefer aggressive treatment[ | ||
Physical capability | Skills | Disease symptom burden | →The greater the burden of symptoms, the less likely patients are to sign advance directives or health care powers of attorney[ |
Opportunity | |||
Social opportunity | Social influences | Family support | →Family members not objecting is an important factor in discussing ACP[ |
Social support | →Patients with higher social support are more willing to engage in ACP[ | ||
Doctor-patient relationship | →Poor doctor-patient relationship leads to low acceptance of ACP[ | ||
Dependent children | →Patients with dependent children are more likely to prefer aggressive treatment and less likely to engage in ACP[ | ||
Physical opportunity | Environmental context and resources | Housing type | →Patients without private housing are more willing to engage in ACP[ |
Hospice service center | →Whether or not to establish a hospice service center is a factor influencing whether or not patients choose to participate in ACP[ | ||
Motivation | |||
Reflective motivation | Intentions | ACP attitude | →The sense of life meaning is the main factor influencing patients' attitude towards ACP[ |
Goals | ACP belief | →Patients want to ensure a comfortable end-of-life and avoid pain[ | |
Beliefs about capabilities | ACP motivation | →The reason that hinders patients from engaging in ACP is that patients think that their relatives can make decisions for them or that their wishes may change in the future[ | |
Automatic motivation | Emotion | Anxiety and depression | →Patients who participated in ACP had significantly higher anxiety and depression scores than those who did not participate in ACP[ |
COM-B | TDF | Facilitator | Barrier |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | Knowledge of ACP[ Education level[ Accurate knowledge of prognosis[ | Knowledge of ACP[ |
Behavioural regulation | Knowledge of the time of disease diagnosis[ Prior experience[ | Subjective life expectancy[ | |
Physical capability | Skills | Age[ Cancer site[ | Disease symptom burden[ |
Opportunity | |||
Social opportunity | Social influences | Marital status[ Race/ethnicity[ Family support[ Doctor-patient relationship[ Religious belief[ Gender[ Social support[ Dependent children[ Acculturation[ | Marital status[ Race/ethnicity[ Family support[ Doctor-patient relationship[ Religious belief[ |
Physical opportunity | Environmental context and resources | Family economic condition[ Place of living[ Housing type[ | Hospice service center[ Place of living[ |
Motivation | |||
Reflective motivation | Intentions | ‒ | ACP attitude[ |
Goals | ACP belief[ | ‒ | |
Beliefs about capabilities | ACP motivation[ | ACP motivation[ | |
Automatic motivation | Emotion | Anxiety and depression[ | Death attitude[ |
Tab 6 Factors influencing ACP engagement behavior of advanced cancer patients coded according to COM-B model
COM-B | TDF | Facilitator | Barrier |
---|---|---|---|
Capability | |||
Psychological capability | Knowledge | Knowledge of ACP[ Education level[ Accurate knowledge of prognosis[ | Knowledge of ACP[ |
Behavioural regulation | Knowledge of the time of disease diagnosis[ Prior experience[ | Subjective life expectancy[ | |
Physical capability | Skills | Age[ Cancer site[ | Disease symptom burden[ |
Opportunity | |||
Social opportunity | Social influences | Marital status[ Race/ethnicity[ Family support[ Doctor-patient relationship[ Religious belief[ Gender[ Social support[ Dependent children[ Acculturation[ | Marital status[ Race/ethnicity[ Family support[ Doctor-patient relationship[ Religious belief[ |
Physical opportunity | Environmental context and resources | Family economic condition[ Place of living[ Housing type[ | Hospice service center[ Place of living[ |
Motivation | |||
Reflective motivation | Intentions | ‒ | ACP attitude[ |
Goals | ACP belief[ | ‒ | |
Beliefs about capabilities | ACP motivation[ | ACP motivation[ | |
Automatic motivation | Emotion | Anxiety and depression[ | Death attitude[ |
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