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Review Article| Volume 22, ISSUE 2, P349.e1-349.e28, February 2021

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Advance Care Planning in Asia: A Systematic Narrative Review of Healthcare Professionals’ Knowledge, Attitude, and Experience

Open AccessPublished:January 06, 2021DOI:https://doi.org/10.1016/j.jamda.2020.12.018
Advance Care Planning in Asia: A Systematic Narrative Review of Healthcare Professionals’ Knowledge, Attitude, and Experience
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      Abstract

      Objective

      The value of advance care planning (ACP) for patients with life-limiting illnesses is widely recognized but Asian health care professionals' (HCPs') perspectives on ACP have received little systematic attention. We aim to synthesize evidence regarding Asian HCPs’ knowledge of, attitudes toward, and experiences with ACP.

      Design

      Systematic review with narrative synthesis and stepwise thematic analysis.

      Setting and Participants

      HCPs in southern, eastern, and southeastern Asia.

      Methods

      Studies from inception to September 2019 were identified from English-language searches of Embase, MEDLINE, Web of Science, and Google Scholar with reference-chaining and hand-searching. Two investigators independently screened and assessed the risk of bias in all original studies reporting HCPs’ knowledge of, attitudes toward, and experiences with ACP, including their perspectives toward barriers and facilitators of ACP.

      Results

      Fifty-one studies were included; 42 were quantitative, 43 had been conducted in high-income countries, and 36 were of good quality. Twenty-six studies operationalized ACP as the completion of an advance directive rather than a value-exploration process. Thirteen studies reported knowledge, 44 attitudes, 29 experiences, and 36 barriers and facilitators of ACP. Asian HCPs addressed the essential role of families in ACP. They acknowledge the importance of ACP but rarely engage the patient in it. They considered ACP difficult to initiate, partly because of their lack of knowledge and skills in ACP, personal uneasiness to conduct ACP, fear of conflicts with family members and their legal consequences, and the lack of a standard system for ACP. Most studies indicated HCPs’ low engagement and late initiation of ACP.

      Conclusions and Implications

      Despite acknowledging its importance, Asian HCPs felt that engaging in ACP is challenging. Capacity building for ACP in Asia should focus on culturally adapting ACP models concerning the essential role of the family in Asia, education for HCPs and the public, and providing institutional support for ACP.

      Keywords

      Complex decisions regarding medical care and treatment often need to be made during life-limiting disease trajectories. If health care professionals (HCPs) do not clearly understand patients’ life goals and care preferences, patients may not always be treated in accordance with their preferences.
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      Advance care planning (ACP) is a process that enables individuals, family members, and HCPs to define, discuss, document, and review goals and preferences for future medical care and treatment.
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      Systematic reviews have shown that ACP has the potential to improve the quality of end-of-life care, the documentation of care preferences, the provision of goal-concordant care, and the use of palliative and hospice care, while potentially reducing the cost.
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      it is now gaining attention in Asia
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      —the largest and most populous continent in the world, and the home of various cultures. Examples of cultural values that may affect the uptake of ACP in Asia include family-centeredness in medical decision making,
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      Central to these values is the great importance of social harmony and interdependence. Meanwhile, Asians require more support from their HCPs to voice their own wishes.
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      Asian HCPs' perspectives on ACP have not been systematically analyzed. We therefore aimed to synthesize and appraise the evidence from Asia with regard to HCPs’ knowledge of ACP, their attitudes toward it, and their experiences with it and also to the barriers and facilitators related to their engagement in ACP.

      Methods

      The study protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018099980). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used for reporting (Supplementary Table 1).
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      Data Sources and Selection

      With the aid of a biomedical information specialist (WMB), we developed a systematic search strategy based on the predetermined research question in the following electronic databases: Embase.com (1971-), MEDLINE ALL Ovid (1946-), Web of Science Core Collection (1975-), and Google Scholar from inception to September 2019. We used the tailored search terms for each database, using thesaurus terms (Emtree and MeSH) where applicable. Supplementary Table 2 shows the full searches for all databases. The searches not only contained words for ACP and advance directive (AD) but also were designed to retrieve articles on decision making for the end of life. To ensure a comprehensive search, we scanned the reference lists from relevant existing literature reviews and from the included articles, and finally asked several experts in the field of ACP in Asia whether important studies that met our inclusion and exclusion criteria had been missed.

      Study Selection

      We did not limit the type of study designs for this review and included all original studies that studied “advance care planning,” or studies that addressed one or both core elements of ACP as defined by the European Association for Palliative Care (EAPC)
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      • Connolly M.
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      Definition and recommendations for advance care planning: An international consensus supported by the European Association for Palliative Care.
      Lancet Oncol. 2017; 18: e543-e551
      :
      • 1.
        discussing patients' goals and/or preferences for future medical care and/or treatment with family and/or HCPs and/or
      • 2.
        recording patients' preferences including the appointment of a personal representative and an AD.
      We defined AD as a document to record values, goals, and preferences to be considered when the individual is unable to express their preferences.
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      • Sudore R.L.
      • Connolly M.
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      Definition and recommendations for advance care planning: An international consensus supported by the European Association for Palliative Care.
      Lancet Oncol. 2017; 18: e543-e551
      AD may include living wills,
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      durable power of attorneys,
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      and do-not-resuscitate (DNR) orders.
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      The Japan HOspice and Palliative Care Evaluation Study (J-HOPE Study): views about legalization of death with dignity and euthanasia among the bereaved whose family member died at palliative care units.
      Am J Hosp Palliat Care. 2009; 26: 98-104
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      Death, dying, and advance directives in Japan: Socio-cultural and legal point of view.
      in: Sass H. Veatch R. Kimura R. Advance Directive and Surrogate Decision Making in Transcultural Perspective. Johns Hopkins University Press, Baltimore, MD1998
      For the aim of this review, we included professionals that the authors had labeled as “health care professionals” or those who followed WHO definition as “professionals who maintain health in humans through the application of the principles and procedures of evidence-based medicine and caring.”
      World Health Organization
      Definition and list of health professionals. In: Transforming and Scaling Up Health Professionals' Education and Training: World Health Organization Guidelines 2013.
      World Health Organization, Geneva2013
      This may include, but is not limited to, physicians, nurses, social workers, and care managers. Because of the sheer size of the Asian continent, we limited our search to its southern, eastern, and southeastern regions (Supplementary Table 3), whose similarities in cultural background provided a reasonable representation of collectivism in Eastern cultures.
      United Nations
      Standard country or area codes for statistical use (M49); 1999.
      https://unstats.un.org/unsd/methodology/m49/
      Date accessed: October 29, 2020
      We included original articles on HCPs' knowledge of, attitudes toward, or experiences with ACP that had been published in English in peer-reviewed journals. We excluded studies in which the specific elements of ACP were not clearly described, and studies on HCPs’ perspectives toward ACP among patients younger than 18 years or patients with psychiatric illnesses other than dementias.
      Duplicates of the retrieved studies were removed, and each title and abstract was screened by 2 of 3 reviewers (D.M., M.S.K., and C.P.L.) independently. This was followed by full-text reviewing for inclusion. Disagreements were discussed with J.R. and/or C.R. if necessary. Endnote bibliographic software version X9 was used to manage references.

      Data Extraction and Quality Assessment

      A tailored data extraction form was developed and piloted by J.R. and C.R. and further used to extract data that included (1) the study characteristics (study design, country or region, the element and term related to ACP studied, number of HCPs, type of HCPs, and setting); (2) HCPs' knowledge of ACP; (3) HCPs' attitudes toward and experiences with ACP; (4) HCPs’ perspectives on barriers and facilitators related to engagement in ACP. The extraction form was completed by DM and checked by MSK.
      We used a 9-item tool developed by Hawker et al
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      to assess the methodologic quality of the included studies. Per study, the risk of bias was evaluated for the following items: (1) abstract and title, (2) introduction and aims, (3) methods and data, (4) sampling, (5) data analysis, (6) ethics and bias, (7) results, (8) transferability, and (9) implications. Each criterion was scored on a 4-point Likert-type scale ranging from 1 (very poor) to 4 (good). In total, a summed score of 9 to 36 was calculated. Studies with scores between 30 and 36 were classified as having a low risk of bias, studies with scores between 24 and 29 were classified as having a moderate risk, and scores lower than 24 were classified as having a high risk.
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      Studies were not excluded on the basis of their methodological quality. D.M. assessed all studies, 50% of which were randomly selected and checked independently by C.P.L.

      Data Synthesis and Analysis

      Following the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews, a narrative synthesis was conducted of the included quantitative, qualitative, and mixed methods studies.
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      To summarize the findings of the included articles, we conducted textual description of the extracted data, tabulation, grouping, and clustering. This was followed by a stepwise thematic analysis. A critical interpretive synthesis approach was used to categorize knowledge, attitudes, experiences, barriers, and facilitators into domains.
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      Results

      Study Selection and Characteristics

      After deduplication, we identified 3887 studies for titles and abstracts screening. Three studies were added following a manual search and input from experts in Asia, and 244 studies were assessed for full-text review. Ultimately, 51 studies were included in the analysis (Figure 1).
      Figure thumbnail gr1
      Fig. 1PRISMA flow diagram for study selection.
      Most of the studies included were quantitative, among which 42 were surveys, 19 were conducted in hospital settings, and most included fewer than 500 HCPs (n = 45), were performed among physicians (n = 42), and were from high-income countries (Table 1 and Supplementary Table 4): Japan,
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      • et al.
      What influences patients’ decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals.
      Palliat Med. 2019; 33: 1299-1309
      Twenty-six studies operationalized ACP merely as the documentation process. The term ACP was used in 12 studies that had been published in the last decade (Tables 1 and 2). Thirteen studies reported on HCPs’ knowledge, 44 studies on attitudes, 29 on experiences, and 36 on barriers and facilitators of ACP. The risk of bias was low in 36 studies, moderate in 13, and high in 2 (Supplementary Table 5).
      Table 1Characteristics of the Included Studies (n = 51)
      Study Characteristicsn (%)
      Type of study
       Quantitative study42 (82)
       Qualitative study7 (14)
       Mixed study2 (4)
      Country or region
      Several studies were multicountry studies.
       Japan16
       South Korea13
       Hong Kong6
       Singapore6
       Taiwan4
       China3
       Others
      Others: India (2), Sri Lanka (1), Thailand (1), and Pakistan (1).
      		5
      Term related to ACP studied
      Several studies used more than 1 term related to ACP.
       Advance care planning12
       Term related to ACP documents
      Advance (medical) directive25
      DN(A)R order/form14
      Living will2
       Term related to ACP conversation
      End-of-life discussion2
      End-of-life (care or medical) decision-making5
      DNR order discussion2
      Code status discussion2
      AD discussion1
      End-of-life care planning1
      The element of ACP studied
       ACP as completion of documents26
       ACP as process of a discussion on preferences11
       Both14
      Number of HCPs in the study
       0-10018
       101-50027
       501-10005
       >10001
      Type of HCPs studied
      Several studies studied more than 1 type of health care professional.
       Physicians42
       Nurses20
       Social workers10
       Case managers1
      Setting
      Several studies were done in more than 1 setting.
       Hospital (not further specified)19
       Oncology7
       Palliative care or hospice4
       Intensive care6
       Geriatric4
       Dialysis2
       Others, no restriction15
      Outcomes of the study
       Knowledge13
       Attitude44
       Experience29
       Barrier and facilitator34
      DN(A)R, do not attempt resuscitation.
      ∗ Several studies were multicountry studies.
      † Others: India (2), Sri Lanka (1), Thailand (1), and Pakistan (1).
      ‡ Several studies used more than 1 term related to ACP.
      § Several studies studied more than 1 type of health care professional.
      ‖ Several studies were done in more than 1 setting.
      Table 2Categories of Asian HCPs Attitudes toward and Experiences with ACP
      Categories (References)Number of Studies
      Asian HCPs' Attitude toward ACP
       HCPs' perceptions of the usefulness/importance of ACP
      • Nakazawa K.
      • Kizawa Y.
      • Maeno T.
      • et al.
      Palliative care physicians' practices and attitudes regarding advance care planning in palliative care units in Japan: A nationwide survey.
      Am J Hosp Palliat Care. 2014; 31: 699-709
      ,
      • Yokoya S.
      • Kizawa Y.
      • Maeno T.
      Practice and perceived importance of advance care planning and difficulties in providing palliative care in geriatric health service facilities in Japan: A nationwide survey.
      Am J Hosp Palliat Care. 2018; 35: 464-472
      ,
      • Asai A.
      • Miura Y.
      • Tanabe N.
      • et al.
      Advance directives and other medical decisions concerning the end of life in cancer patients in Japan.
      Eur J Cancer. 1998; 34: 1582-1586
      , 
      • Voltz R.
      • Akabayashi A.
      • Reese C.
      • et al.
      End-of-life decisions and advance directives in palliative care: A cross-cultural survey of patients and health-care professionals.
      J Pain Symptom Manage. 1998; 16: 153-162
      , 
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      , 
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Asai A.
      • Fukuhara S.
      • Inoshita O.
      • et al.
      Medical decisions concerning the end of life: A discussion with Japanese physicians.
      J Med Ethics. 1997; 23: 323-327
      ,
      • Keam B.
      • Yun Y.H.
      • Heo D.S.
      • et al.
      The attitudes of Korean cancer patients, family caregivers, oncologists, and members of the general public toward advance directives.
      Support Care Cancer. 2013; 21: 1437-1444
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      , 
      • Chan C.W.H.
      • Wong M.M.H.
      • Choi K.C.
      • et al.
      What patients, families, health professionals and hospital volunteers told us about advance directives.
      Asia Pac J Oncol Nurs. 2019; 6: 72-77
      , 
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      		15
       Whether or not HCPs supported the use of AD
      • Yaguchi A.
      • Truog R.D.
      • Curtis J.R.
      • et al.
      International differences in end-of-life attitudes in the intensive care unit: Results of a survey.
      Arch Intern Med. 2005; 165: 1970-1975
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Kim S.
      • Lee Y.
      Korean nurses' attitudes to good and bad death, life-sustaining treatment and advance directives.
      Nurs Ethics. 2003; 10: 624-637
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      , 
      • Kumar S.
      • Chaudhary S.
      "Do not resuscitate" orders in Delhi.
      Natl Med J India. 1991; 4: 125-126
      , 
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      		9
       HCPs' confidence about engaging in ACP
      • Hiraoka E.
      • Homma Y.
      • Norisue Y.
      • et al.
      What is the true definition of a “do-not-resuscitate” order? A Japanese perspective.
      Int J Gen Med. 2016; 9: 213-220
      ,
      • Voltz R.
      • Akabayashi A.
      • Reese C.
      • et al.
      End-of-life decisions and advance directives in palliative care: A cross-cultural survey of patients and health-care professionals.
      J Pain Symptom Manage. 1998; 16: 153-162
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
      ,
      • Lee M.C.
      • Auth R.
      • Hinderer K.A.
      • et al.
      Challenges to advance care planning among multidisciplinary health professionals in China.
      Int J Palliat Nurs. 2017; 23: 552-557
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      		5
       The role HCPs perceived for themselves in ACP
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.
      Palliat Support Care. 2016; 14: 69-76
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Ke Y.X.
      • Hu S.H.
      • Takemura N.
      • et al.
      Perceived quality of palliative care in intensive care units among doctors and nurses in Taiwan.
      Int J Qual Health. 2019; 31: 741-747
      		5
       HCPs' willingness to engage in ACP
      • Park S.Y.
      • Phua J.
      • Nishimura M.
      • et al.
      End-of-life care in ICUs in East Asia: A comparison among China, Korea, and Japan.
      Crit Care Med. 2018; 46: 1114-1124
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Luk Y.
      • Ngai C.
      • Chau S.S.
      • et al.
      Clinicians' experience with and attitudes toward discussing advance directives with terminally ill patients and their families in a Chinese community.
      J Palliat Med. 2015; 18: 794-798
      ,
      • Chao C.S.
      Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.
      J Nurs Res. 2002; 10: 161-167
      		4
       Who HCPs believed should participate in ACP
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Yap H.Y.
      • Joynt G.M.
      • Gomersall C.D.
      Ethical attitudes of intensive care physicians in Hong Kong: Questionnaire survey.
      Hong Kong Med J. 2004; 10: 244-250
      ,
      • Yang G.M.
      • Kwee A.K.
      • Krishna L.
      Should patients and family be involved in "Do Not Resuscitate" decisions? Views of oncology and palliative care doctors and nurses.
      Indian J Palliat Care. 2012; 18: 52-58
      ,
      • Barnett V.
      • Aurora V.
      Physician beliefs and practice regarding end-of-life care in India.
      Indian J Crit Care Med. 2008; 12: 109-115
      , 
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      , 
      • Weng L.
      • Joynt G.M.
      • Lee A.
      • et al.
      Attitudes towards ethical problems in critical care medicine: The Chinese perspective.
      Intensive Care Med. 2011; 37: 655-664
      		7
       HCPs' willingness to follow an AD
      • Sehgal A.R.
      • Weisheit C.
      • Miura Y.
      • et al.
      Advance directives and withdrawal of dialysis in the United States, Germany, and Japan.
      J Am Med Assoc. 1996; 276: 1652-1656
      ,
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      , 
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      , 
      • Asai A.
      • Maekawa M.
      • Akiguchi I.
      • et al.
      Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state.
      J Med Ethics. 1999; 25: 302-308
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Yap H.Y.
      • Joynt G.M.
      • Gomersall C.D.
      Ethical attitudes of intensive care physicians in Hong Kong: Questionnaire survey.
      Hong Kong Med J. 2004; 10: 244-250
      ,
      • Foo W.T.
      • Zheng Y.
      • Kwee A.K.
      • et al.
      Factors considered in end-of-life care decision making by health care professionals.
      Am J Hosp Palliat Med. 2013; 30: 354-358
      ,
      • Weng L.
      • Joynt G.M.
      • Lee A.
      • et al.
      Attitudes towards ethical problems in critical care medicine: The Chinese perspective.
      Intensive Care Med. 2011; 37: 655-664
      ,
      • Sittisombut S.
      • Maxwell C.
      • Love E.J.
      • et al.
      Physicians' attitudes and practices regarding advanced end-of-life care planning for terminally ill patients at Chiang Mai University Hospital, Thailand.
      Nurs Health Sci. 2009; 11: 23-28
      		9
       Who HCPs believed should be the decision maker in ACP
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      , 
      • Yang G.M.
      • Kwee A.K.
      • Krishna L.
      Should patients and family be involved in "Do Not Resuscitate" decisions? Views of oncology and palliative care doctors and nurses.
      Indian J Palliat Care. 2012; 18: 52-58
      , 
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      ,
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      ,
      • Barnett V.
      • Aurora V.
      Physician beliefs and practice regarding end-of-life care in India.
      Indian J Crit Care Med. 2008; 12: 109-115
      		8
       Which factors HCPs believed influenced decision making
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      , 
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      , 
      • Asai A.
      • Maekawa M.
      • Akiguchi I.
      • et al.
      Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state.
      J Med Ethics. 1999; 25: 302-308
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      		4
       HCPs' perceptions regarding the optimal timing to initiate ACP
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      , 
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      , 
      • Keam B.
      • Yun Y.H.
      • Heo D.S.
      • et al.
      The attitudes of Korean cancer patients, family caregivers, oncologists, and members of the general public toward advance directives.
      Support Care Cancer. 2013; 21: 1437-1444
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.
      Palliat Support Care. 2016; 14: 69-76
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      ,
      • Chan C.W.H.
      • Wong M.M.H.
      • Choi K.C.
      • et al.
      What patients, families, health professionals and hospital volunteers told us about advance directives.
      Asia Pac J Oncol Nurs. 2019; 6: 72-77
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Yang G.M.
      • Kwee A.K.
      • Krishna L.
      Should patients and family be involved in "Do Not Resuscitate" decisions? Views of oncology and palliative care doctors and nurses.
      Indian J Palliat Care. 2012; 18: 52-58
      ,
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      		14
       HCPs' beliefs on the need for ACP training and education
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Lin C.P.
      • Evans C.J.
      • Koffman J.
      • et al.
      What influences patients’ decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals.
      Palliat Med. 2019; 33: 1299-1309
      		5
       HCPs' beliefs on the need for legislation and standardization of ACP
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Luk Y.
      • Ngai C.
      • Chau S.S.
      • et al.
      Clinicians' experience with and attitudes toward discussing advance directives with terminally ill patients and their families in a Chinese community.
      J Palliat Med. 2015; 18: 794-798
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Chao C.S.
      Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.
      J Nurs Res. 2002; 10: 161-167
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      		8
      Asian HCPs' Experience with ACP
       HCPs who had received an AD
      • Sehgal A.R.
      • Weisheit C.
      • Miura Y.
      • et al.
      Advance directives and withdrawal of dialysis in the United States, Germany, and Japan.
      J Am Med Assoc. 1996; 276: 1652-1656
      ,
      • Asai A.
      • Miura Y.
      • Tanabe N.
      • et al.
      Advance directives and other medical decisions concerning the end of life in cancer patients in Japan.
      Eur J Cancer. 1998; 34: 1582-1586
      ,
      • Asai A.
      • Maekawa M.
      • Akiguchi I.
      • et al.
      Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state.
      J Med Ethics. 1999; 25: 302-308
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Coffey A.
      • McCarthy G.
      • Weathers E.
      • et al.
      Nurses' knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five countries.
      Int J Nurs Pract. 2016; 22: 247-257
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      		7
       HCPs who had engaged in ACP
      • Nakazawa K.
      • Kizawa Y.
      • Maeno T.
      • et al.
      Palliative care physicians' practices and attitudes regarding advance care planning in palliative care units in Japan: A nationwide survey.
      Am J Hosp Palliat Care. 2014; 31: 699-709
      ,
      • Yokoya S.
      • Kizawa Y.
      • Maeno T.
      Practice and perceived importance of advance care planning and difficulties in providing palliative care in geriatric health service facilities in Japan: A nationwide survey.
      Am J Hosp Palliat Care. 2018; 35: 464-472
      ,
      • Hiraoka E.
      • Homma Y.
      • Norisue Y.
      • et al.
      What is the true definition of a “do-not-resuscitate” order? A Japanese perspective.
      Int J Gen Med. 2016; 9: 213-220
      ,
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Yap H.Y.
      • Joynt G.M.
      • Gomersall C.D.
      Ethical attitudes of intensive care physicians in Hong Kong: Questionnaire survey.
      Hong Kong Med J. 2004; 10: 244-250
      ,
      • Luk Y.
      • Ngai C.
      • Chau S.S.
      • et al.
      Clinicians' experience with and attitudes toward discussing advance directives with terminally ill patients and their families in a Chinese community.
      J Palliat Med. 2015; 18: 794-798
      ,
      • Coffey A.
      • McCarthy G.
      • Weathers E.
      • et al.
      Nurses' knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five countries.
      Int J Nurs Pract. 2016; 22: 247-257
      , 
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      , 
      • Chan C.W.H.
      • Wong M.M.H.
      • Choi K.C.
      • et al.
      What patients, families, health professionals and hospital volunteers told us about advance directives.
      Asia Pac J Oncol Nurs. 2019; 6: 72-77
      , 
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Ke Y.X.
      • Hu S.H.
      • Takemura N.
      • et al.
      Perceived quality of palliative care in intensive care units among doctors and nurses in Taiwan.
      Int J Qual Health. 2019; 31: 741-747
      ,
      • Hu W.Y.
      • Huang C.H.
      • Chiu T.Y.
      • et al.
      Factors that influence the participation of healthcare professionals in advance care planning for patients with terminal cancer: A nationwide survey in Taiwan.
      Soc Sci Med. 2010; 70: 1701-1704
      ,
      • Sittisombut S.
      • Maxwell C.
      • Love E.J.
      • et al.
      Physicians' attitudes and practices regarding advanced end-of-life care planning for terminally ill patients at Chiang Mai University Hospital, Thailand.
      Nurs Health Sci. 2009; 11: 23-28
      		17
       Who (ie, patients and families) had participated in ACP
      • Park S.Y.
      • Phua J.
      • Nishimura M.
      • et al.
      End-of-life care in ICUs in East Asia: A comparison among China, Korea, and Japan.
      Crit Care Med. 2018; 46: 1114-1124
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Yap H.Y.
      • Joynt G.M.
      • Gomersall C.D.
      Ethical attitudes of intensive care physicians in Hong Kong: Questionnaire survey.
      Hong Kong Med J. 2004; 10: 244-250
      ,
      • Sittisombut S.
      • Maxwell C.
      • Love E.J.
      • et al.
      Physicians' attitudes and practices regarding advanced end-of-life care planning for terminally ill patients at Chiang Mai University Hospital, Thailand.
      Nurs Health Sci. 2009; 11: 23-28
      		4
       Who had been the decision maker in ACP
      • Asai A.
      • Fukuhara S.
      • Inoshita O.
      • et al.
      Medical decisions concerning the end of life: A discussion with Japanese physicians.
      J Med Ethics. 1997; 23: 323-327
      ,
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      		2
       HCPs who had followed an AD
      • Nakazawa K.
      • Kizawa Y.
      • Maeno T.
      • et al.
      Palliative care physicians' practices and attitudes regarding advance care planning in palliative care units in Japan: A nationwide survey.
      Am J Hosp Palliat Care. 2014; 31: 699-709
      ,
      • Sehgal A.R.
      • Weisheit C.
      • Miura Y.
      • et al.
      Advance directives and withdrawal of dialysis in the United States, Germany, and Japan.
      J Am Med Assoc. 1996; 276: 1652-1656
      ,
      • Asai A.
      • Miura Y.
      • Tanabe N.
      • et al.
      Advance directives and other medical decisions concerning the end of life in cancer patients in Japan.
      Eur J Cancer. 1998; 34: 1582-1586
      ,
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.
      Palliat Support Care. 2016; 14: 69-76
      ,
      • Yap H.Y.
      • Joynt G.M.
      • Gomersall C.D.
      Ethical attitudes of intensive care physicians in Hong Kong: Questionnaire survey.
      Hong Kong Med J. 2004; 10: 244-250
      ,
      • Barnett V.
      • Aurora V.
      Physician beliefs and practice regarding end-of-life care in India.
      Indian J Crit Care Med. 2008; 12: 109-115
      		10
       When ACP had been initiated
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      		1
       Whether HCPs had had ACP-related training and education
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      		2
       The presence of guideline or formal regulation for ACP
      • Chao C.S.
      Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.
      J Nurs Res. 2002; 10: 161-167
      		1
       HCPs who had experienced any negative or positive consequences of ACP
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      		3

      Asian HCPs’ Knowledge of ACP

      Eleven of the 13 studies on HCPs’ knowledge of ACP assessed their knowledge of the documents related to ACP, such as ADs or DNR orders (Supplementary Table 6).
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
      ,
      • Han S.
      The effects of South Korean social workers' professional resources on their understanding of a patient's right to end-of-life care decisions in long-term care facilities.
      Asian Soc Work Policy Rev. 2016; 10: 200-209
      ,
      • Hong S.
      • Kim S.
      • Park K.O.
      • et al.
      Awareness of advance directives among Korean nurses.
      Holist Nurs Pract. 2012; 26: 277-282
      ,
      • Luk Y.
      • Ngai C.
      • Chau S.S.
      • et al.
      Clinicians' experience with and attitudes toward discussing advance directives with terminally ill patients and their families in a Chinese community.
      J Palliat Med. 2015; 18: 794-798
      ,
      • Coffey A.
      • McCarthy G.
      • Weathers E.
      • et al.
      Nurses' knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five countries.
      Int J Nurs Pract. 2016; 22: 247-257
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Ke Y.X.
      • Hu S.H.
      • Takemura N.
      • et al.
      Perceived quality of palliative care in intensive care units among doctors and nurses in Taiwan.
      Int J Qual Health. 2019; 31: 741-747
      ,
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      ,
      • Kumar S.
      • Chaudhary S.
      "Do not resuscitate" orders in Delhi.
      Natl Med J India. 1991; 4: 125-126
      In Hong Kong, 57% of the physicians
      • Luk Y.
      • Ngai C.
      • Chau S.S.
      • et al.
      Clinicians' experience with and attitudes toward discussing advance directives with terminally ill patients and their families in a Chinese community.
      J Palliat Med. 2015; 18: 794-798
      and 49% of the nurses
      • Coffey A.
      • McCarthy G.
      • Weathers E.
      • et al.
      Nurses' knowledge of advance directives and perceived confidence in end-of-life care: A cross-sectional study in five countries.
      Int J Nurs Pract. 2016; 22: 247-257
      were familiar with ADs, as were 40% to 61% of the physicians and 56% of the nurses in South Korea.
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      In Singapore, general practitioners answered 80% to 88% of the 8 questions on AD correctly.
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      Taiwanese nurses and intensivists provided correct answers to fewer than 5 of the 10 questions on their knowledge of ADs.
      • Ke Y.X.
      • Hu S.H.
      • Takemura N.
      • et al.
      Perceived quality of palliative care in intensive care units among doctors and nurses in Taiwan.
      Int J Qual Health. 2019; 31: 741-747
      In Sri Lanka, while 67% of physicians had heard of DNR orders and 21% of ADs, only half of them (26% and 12%, respectively) understood the correct meanings of the terms.
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      In Singapore, physicians and social workers answered a mean of 8 out of 9 questions correctly, while nurses answered 6 questions correctly.
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      In a qualitative study, more physicians than nurses and medical social workers had heard of ACP, but few of them understood it as a series of conversations.
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214

      Asian HCPs’ Attitudes Toward and Experiences With ACP

      We synthesized the findings from 41 studies reporting Asian HCPs' attitudes toward ACP and 30 studies reporting Asian HCPs’ experiences with ACP into 12 and 9 categories based on the similar outcomes reported (see Table 3 and Supplementary Tables 7 and 8).
      Table 3HCPs- and System-Related Barriers and Facilitators of ACP in Asia According to HCPs
      HCP-Related Barriers and Facilitators
      HCP-Related BarriersHCP-Related Facilitators
      HCPs limited knowledge about and skills regarding ACPHCPs competence in ACP and EOL care
       HCPs' limited knowledge about and skills regarding EOL care (incl. prognostication) and ACP
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Tsuruwaka M.
      • Yokose R.
      Barriers to promoting advance care planning for residents living in a sanatorium for Hansen's disease: A qualitative study of residents and staff in Japan.
      Asian Bioeth Rev. 2018; 10: 199-217
      ,
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      ,
      • Lin C.P.
      • Evans C.J.
      • Koffman J.
      • et al.
      What influences patients’ decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals.
      Palliat Med. 2019; 33: 1299-1309
      ,
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      		 HCPs' knowledge and skills in end-of-life care (incl. prognostication) and ACP
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Yokoya S.
      • Kizawa Y.
      • Maeno T.
      Practice and perceived importance of advance care planning and difficulties in providing palliative care in geriatric health service facilities in Japan: A nationwide survey.
      Am J Hosp Palliat Care. 2018; 35: 464-472
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Hu W.Y.
      • Huang C.H.
      • Chiu T.Y.
      • et al.
      Factors that influence the participation of healthcare professionals in advance care planning for patients with terminal cancer: A nationwide survey in Taiwan.
      Soc Sci Med. 2010; 70: 1701-1704
       HCPs' concerns that patients' preferences may change over time
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kim S.
      • Lee Y.
      Korean nurses' attitudes to good and bad death, life-sustaining treatment and advance directives.
      Nurs Ethics. 2003; 10: 624-637
      ,
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      HCPs' personal uneasiness with regard to conducting ACPHCPs' positive attitudes toward fostering patient's autonomy
       HCPs' uneasiness about discontinuing life-supporting treatments
      • Asai A.
      • Fukuhara S.
      • Inoshita O.
      • et al.
      Medical decisions concerning the end of life: A discussion with Japanese physicians.
      J Med Ethics. 1997; 23: 323-327
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      ,
      • Chao C.S.
      Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.
      J Nurs Res. 2002; 10: 161-167
      ,
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      		 HCPs' positive attitudes toward fostering patients' autonomy
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Asai A.
      • Miura Y.
      • Tanabe N.
      • et al.
      Advance directives and other medical decisions concerning the end of life in cancer patients in Japan.
      Eur J Cancer. 1998; 34: 1582-1586
      ,
      • Asai A.
      • Fukuhara S.
      • Inoshita O.
      • et al.
      Medical decisions concerning the end of life: A discussion with Japanese physicians.
      J Med Ethics. 1997; 23: 323-327
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Kim S.
      • Lee Y.
      Korean nurses' attitudes to good and bad death, life-sustaining treatment and advance directives.
      Nurs Ethics. 2003; 10: 624-637
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Lin C.P.
      • Evans C.J.
      • Koffman J.
      • et al.
      What influences patients’ decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals.
      Palliat Med. 2019; 33: 1299-1309
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
       HCPs being more inclined to the curative intent of medicine
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Tsuruwaka M.
      • Yokose R.
      Barriers to promoting advance care planning for residents living in a sanatorium for Hansen's disease: A qualitative study of residents and staff in Japan.
      Asian Bioeth Rev. 2018; 10: 199-217
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      ,
      • Lin C.P.
      • Evans C.J.
      • Koffman J.
      • et al.
      What influences patients’ decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals.
      Palliat Med. 2019; 33: 1299-1309
      ,
      • Kumar S.
      • Chaudhary S.
      "Do not resuscitate" orders in Delhi.
      Natl Med J India. 1991; 4: 125-126
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      ,
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      		 HCPs' understanding of cultural relevance to EOL issues
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
       HCPs' concern of patients receiving suboptimal care after signing ACP's document
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Yang G.M.
      • Kwee A.K.
      • Krishna L.
      Should patients and family be involved in "Do Not Resuscitate" decisions? Views of oncology and palliative care doctors and nurses.
      Indian J Palliat Care. 2012; 18: 52-58
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      ,
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      		 HCPs' feeling comfortable with engaging in EOL discussions
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
       HCPs concern that engaging in ACP means advocating euthanasia
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      		 HCPs' positive attitudes toward hospice and palliative care
      • Keam B.
      • Yun Y.H.
      • Heo D.S.
      • et al.
      The attitudes of Korean cancer patients, family caregivers, oncologists, and members of the general public toward advance directives.
      Support Care Cancer. 2013; 21: 1437-1444
      ,
      • Kwon S.A.
      • Kolomer S.
      Advance care planning in South Korea: Social work perspective.
      Soc Work Health Care. 2016; 55: 545-558
       HCPs' uneasiness about engaging in EOL discussions
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Tsuruwaka M.
      • Yokose R.
      Barriers to promoting advance care planning for residents living in a sanatorium for Hansen's disease: A qualitative study of residents and staff in Japan.
      Asian Bioeth Rev. 2018; 10: 199-217
      , 
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      , 
      • Asai A.
      • Fukuhara S.
      • Inoshita O.
      • et al.
      Medical decisions concerning the end of life: A discussion with Japanese physicians.
      J Med Ethics. 1997; 23: 323-327
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      • et al.
      Experiences and opinions related to end-of-life discussion: From oncologists' and resident physicians' perspectives.
      Cancer Res Treat. 2018; 50: 614-623
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      ,
      • Chao C.S.
      Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.
      J Nurs Res. 2002; 10: 161-167
      ,
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      		 HCPs' beliefs on the benefits of ACP
      • Mori M.
      • Shimizu C.
      • Ogawa A.
      • et al.
      A national survey to systematically identify factors associated with oncologists' attitudes toward end-of-life discussions: what determines timing of end-of-life discussions?.
      Oncologist. 2015; 20: 1304-1311
      ,
      • Asai A.
      • Miura Y.
      • Tanabe N.
      • et al.
      Advance directives and other medical decisions concerning the end of life in cancer patients in Japan.
      Eur J Cancer. 1998; 34: 1582-1586
      ,
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Asai A.
      • Fukuhara S.
      • Inoshita O.
      • et al.
      Medical decisions concerning the end of life: A discussion with Japanese physicians.
      J Med Ethics. 1997; 23: 323-327
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Lee J.E.
      • Goo A.
      • Shin D.W.
      • et al.
      Korean medical professionals' attitudes and experiences on advance care planning for noncancerous disease.
      Ann Geriatr Med Res. 2019; 23: 63-70
      ,
      • Kim S.
      • Lee Y.
      Korean nurses' attitudes to good and bad death, life-sustaining treatment and advance directives.
      Nurs Ethics. 2003; 10: 624-637
      ,
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      ,
      • Pinto M.V.G.
      • Varun R.
      • Wanasinghe W.M.M.P.B.
      • Jayasinghearachchi T.M.K.
      A cross-sectional study of knowledge and attitudes of medical professionals towards end-of-life decisions in teaching hospitals of Kandy District (Sri Lanka).
      Anaesth Pain Intensive Care. 2013; 17: 40-44
      , 
      • Kumar S.
      • Chaudhary S.
      "Do not resuscitate" orders in Delhi.
      Natl Med J India. 1991; 4: 125-126
      , 
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
       HCPs' belief that discussing EOL with the patient challenges the local culture (eg filial piety and social hierarchy)
      • Park S.Y.
      • Phua J.
      • Nishimura M.
      • et al.
      End-of-life care in ICUs in East Asia: A comparison among China, Korea, and Japan.
      Crit Care Med. 2018; 46: 1114-1124
      ,
      • Tsuruwaka M.
      • Yokose R.
      Barriers to promoting advance care planning for residents living in a sanatorium for Hansen's disease: A qualitative study of residents and staff in Japan.
      Asian Bioeth Rev. 2018; 10: 199-217
      ,
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Menon S.
      • Kars M.C.
      • Malhotra C.
      • et al.
      Advance care planning in a multicultural family centric community: A qualitative study of health care professionals', patients', and caregivers' perspectives.
      J Pain Symptom Manage. 2018; 56: 213-221.e214
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      ,
      • Sittisombut S.
      • Maxwell C.
      • Love E.J.
      • et al.
      Physicians' attitudes and practices regarding advanced end-of-life care planning for terminally ill patients at Chiang Mai University Hospital, Thailand.
      Nurs Health Sci. 2009; 11: 23-28
      		 HCPs' positive attitudes toward legalization of ACP
      • Hu W.Y.
      • Huang C.H.
      • Chiu T.Y.
      • et al.
      Factors that influence the participation of healthcare professionals in advance care planning for patients with terminal cancer: A nationwide survey in Taiwan.
      Soc Sci Med. 2010; 70: 1701-1704
      System-Related Barriers and Facilitators
      System-Related BarriersSystem-Related Facilitators
      Lack of a standard system and institutional support for ACPThe availability of legal and standard systems for ACP
       Lack of policy and formal regulation of ACP
      • Hosaka T.
      • Kobayashi I.
      • Miyamoto T.
      • et al.
      Physicians' perspectives on “do-not-resuscitate” (DNR) orders.
      Int J Clin Oncol. 1999; 4: 138-141
      ,
      • Hosaka T.
      • Nagano H.
      • Inomata C.
      • et al.
      Nurses' perspectives concerning do-not-resuscitate (DNR) orders.
      Tokai J Exp Clin Med. 1999; 24: 29-34
      ,
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      ,
      • Kumar S.
      • Chaudhary S.
      "Do not resuscitate" orders in Delhi.
      Natl Med J India. 1991; 4: 125-126
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
      ,
      • Syed A.A.
      • Almas A.
      • Naeem Q.
      • et al.
      Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study.
      Palliat Med. 2017; 31: 147-157
      		 Availability of policy and formal regulation of ACP
      • Lee J.
      • Kim K.H.
      Perspectives of Korean patients, families, physicians and nurses on advance directives.
      Asian Nurs Res. 2010; 4: 185-193
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.
      Palliat Support Care. 2016; 14: 69-76
      ,
      • Luk Y.
      • Ngai C.
      • Chau S.S.
      • et al.
      Clinicians' experience with and attitudes toward discussing advance directives with terminally ill patients and their families in a Chinese community.
      J Palliat Med. 2015; 18: 794-798
      ,
      • Tee K.H.
      • Seet L.T.
      • Tan W.C.
      • et al.
      Advance directive: A study on the knowledge and attitudes among general practitioners in Singapore.
      Singapore Med J. 1997; 38: 145-148
      ,
      • Chao C.S.
      Physicians attitudes toward DNR of terminally ill cancer patients in Taiwan.
      J Nurs Res. 2002; 10: 161-167
      ,
      • Chen H.P.
      • Huang B.Y.
      • Yi T.W.
      • et al.
      Attitudes of Chinese oncology physicians toward death with dignity.
      J Palliat Med. 2016; 19: 874-878
       Lack of standard strategies to implement ACP
      • Tsuruwaka M.
      • Yokose R.
      Barriers to promoting advance care planning for residents living in a sanatorium for Hansen's disease: A qualitative study of residents and staff in Japan.
      Asian Bioeth Rev. 2018; 10: 199-217
      ,
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
      		 Availability of a standard system for ACP
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Park Y.R.
      • Kim J.A.
      • Kim K.
      Changes in how ICU nurses perceive the DNR decision and their nursing activity after implementing it.
      Nurs Ethics. 2011; 18: 802-813
      ,
      • Koh S.J.
      • Kim S.
      • Kim J.
      Communication for end-of-life care planning among Korean patients with terminal cancer: A context-oriented model.
      Palliat Support Care. 2016; 14: 69-76
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      ,
      • Tan W.S.
      • Car J.
      • Lall P.
      • et al.
      Implementing advance care planning in acute hospitals: Leading the transformation of norms.
      J Am Geriatr Soc. 2019; 67: 1278-1285
       Lack of training and education related to ACP
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,
      • Masuda Y.
      • Fetters M.D.
      • Hattori A.
      • et al.
      Physicians's reports on the impact of living wills at the end of life in Japan.
      J Med Ethics. 2003; 29: 248-252
      ,
      • Park H.Y.
      • Kim Y.A.
      • Sim J.A.
      • et al.
      Attitudes of the general public, cancer patients, family caregivers, and physicians toward advance care planning: A nationwide survey before the enforcement of the life-sustaining treatment decision-making Act.
      J Pain Symptom Manage. 2019; 57: 774-782
      ,
      • Kim J.
      • Kim S.
      • Hong S.
      Facilitators and barriers to use of advance directives in Korea.
      J Hosp Palliat Nurs. 2013; 15: 410-418
      ,
      • Lam K.W.
      • Yeung K.W.
      • Lai K.Y.
      • et al.
      Changes in the attitude and practice toward end-of-life care: Perspective of Chinese physicians in medical department.
      Am J Hosp Palliat Care. 2015; 32: 549-554
      ,
      • Yee A.
      • Seow Y.Y.
      • Tan S.H.
      • et al.
      What do renal health-care professionals in Singapore think of advance care planning for patients with end-stage renal disease?.
      Nephrology. 2011; 16: 232-238
      ,
      • Lin C.P.
      • Evans C.J.
      • Koffman J.
      • et al.
      What influences patients’ decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals.
      Palliat Med. 2019; 33: 1299-1309
      		 Training and education related to ACP
      • Hirakawa Y.
      • Chiang C.
      • Yasuda Uemura M.
      • et al.
      Involvement of Japanese care managers and social workers in advance care planning.
      J Soc Work End Life Palliat Care. 2018; 14: 315-327
      ,