Family Ties Shape Whether Older Chinese Adults Accept Advance Care Planning, Nationwide Survey Finds

When an older adult in China sits down to think about how they want to be cared for at the end of life, the answer may depend less on their own health than on the family standing around them. A nationwide cross-sectional survey of 4,120 older adults across mainland China has found that a cluster of family-related characteristics, from household structure to how openly relatives talk with one another, is associated with whether older people accept advance care planning, the process of deciding and communicating preferences for future medical care before a crisis arrives. The study, published in BMC Health Services Research, offers one of the broadest portraits yet of how family context intertwines with end-of-life decision-making in a country where such conversations have long been shaped by cultural norms of filial duty and collective decision-making.

Advance care planning, often abbreviated as ACP, is a technical term for something deceptively simple: helping people articulate, while they still can, what kind of treatment they would want if they became unable to speak for themselves. It encompasses naming a surrogate decision-maker, documenting preferences about life-sustaining interventions, and discussing these wishes with clinicians and loved ones. In Western health systems, ACP has been promoted for decades as a way to align care with patient values, reduce unwanted intensive interventions, and ease the burden on families forced to guess at a relative’s wishes. In China, however, the practice has faced distinctive headwinds. Traditional beliefs hold that discussing death openly can bring misfortune, and medical decisions are frequently made by families rather than disclosed fully to patients, particularly when a diagnosis is considered serious.

The research team, led by Yujie Wu of Xi’an Siyuan University together with colleagues at Harbin Medical University and City University of Hong Kong, set out to address a gap in the evidence. Previous studies of ACP acceptance in China had largely concentrated on specific populations, such as patients with cancer or chronic illness, or had examined individual family characteristics in isolation. What remained unclear was the combined contribution of multiple family-related contexts, including family structure, family health, family communication, and the family’s social standing in the community, to ACP acceptance among the general older population. The new survey was designed to capture that broader picture using a multi-stage sampling method that reached older adults across the country’s regions between June and August 2022.

The scale of the data collection is notable. Respondents aged 60 and above were recruited from across mainland China, and self-reported acceptance of ACP was measured with a single-item visual analogue scale, a technique in which participants rate their acceptance on a continuous scale rather than choosing from fixed categories. The mean score came in at 62.78 with a standard deviation of 24.59, suggesting that, on average, older Chinese adults lean toward acceptance but with enormous variability from person to person. That spread is itself a finding: acceptance of end-of-life planning is far from uniform, and understanding what accompanies high versus low acceptance is the central analytical task of the study.

To identify the factors associated with acceptance, the researchers used stepwise linear regression, an exploratory statistical approach in which variables are added or removed from a model according to whether they improve its explanatory power. The team examined a wide array of characteristics, including chronic disease status, region of residence, household composition, sibling count, experience of injury events, attitudes toward death education, neighbor relationships, family social status, family health, family communication, and household finances. Family health and family communication were measured with validated instruments, the Family Health Scale-Short Form and the Family Communication Scale-10, giving the analysis technical grounding beyond simple self-reports.

The adjusted results reveal a striking pattern of negative associations. Older adults with chronic disease, those living in Western China, those in nuclear families, and those with siblings reported lower acceptance of ACP. The chronic disease association may seem counterintuitive at first glance, since one might expect people managing long-term illness to be more receptive to planning ahead. Yet the finding resonates with qualitative research suggesting that in the Chinese cultural context, families sometimes shield relatives with serious illness from information about their condition, and patients themselves may avoid conversations that could be read as giving up. Living in a nuclear family rather than an extended household was also linked to lower acceptance, hinting that the presence of a wider web of relatives may create more occasions for end-of-life discussions to surface naturally.

On the positive side of the ledger, several characteristics were associated with higher acceptance. Older adults who had experienced injury events, who supported death education more strongly, who reported better neighbor relationships, who perceived higher family social status, who described better family health and better family communication, and who had household debts all reported greater acceptance of ACP. Some of these associations invite careful interpretation. The link between injury events and acceptance could reflect a salience effect, in which a brush with harm makes future vulnerability concrete and motivates planning. The debt association is more puzzling but may connect to financial realism: people who have confronted economic precarity may be more attuned to the costs of uncontrolled end-of-life care and more willing to think ahead about what they would and would not want.

Perhaps the most technically important result concerns the incremental contribution of the family-related factors themselves. When the researchers added family context variables to the model, the explained variance increased by 5.2 percent. That figure is meaningful but modest, and the standardized coefficients for most family-related variables were small. The authors are explicit about what this does and does not mean. Family context appears to be one component of a broader set of factors related to ACP acceptance, not the dominant force. Individual attitudes, cultural beliefs, health system exposure, and other unmeasured characteristics likely account for the larger share of the variability in acceptance. The study also cannot establish determinants or causal effects, since a cross-sectional survey captures associations at a single point in time and cannot demonstrate that family characteristics cause changes in acceptance, nor can it show the feasibility or effectiveness of family-centered ACP interventions.

The regional finding, that older adults in Western China reported lower acceptance than those elsewhere, adds a geographic dimension to the analysis. Western China encompasses provinces with lower average incomes, thinner health infrastructure, and populations that include many rural and ethnic minority communities. Differences in health literacy, access to palliative care services, and exposure to discussions about end-of-life options could all contribute to the gap. If ACP is to be promoted nationally, the results suggest that a one-size-fits-all campaign may miss the mark, and that regionally tailored approaches, sensitive to local economic conditions and family norms, may be needed.

For clinicians, policymakers, and families, the survey carries a practical message wrapped in an honest caveat. The associations identified here, from family communication to neighbor relationships to household structure, offer concrete entry points for interventions that hope to normalize end-of-life conversations. Programs that strengthen family communication skills, integrate death education into community health services, and engage the wider social network around older adults may find more traction than efforts aimed at individuals alone. At the same time, the modest 5.2 percent increase in explained variance warns against overpromising: changing acceptance of advance care planning will likely require attention to the full ecosystem of factors surrounding older adults, not family dynamics in isolation. As China’s population ages at one of the fastest rates in the world, the question of how families and health systems together prepare for the end of life is becoming impossible to defer, and studies like this one provide the empirical map from which that preparation must be drawn.

Subject of Research: Health Services Research

Article Title: Family-related factors associated with acceptance of advance care planning among older adults in China: a nationwide cross-sectional survey

Article References: Wu, Y., Liang, C., Li, C., Yue, F., Sun, X., Wu, S., Liu, Y., Yu, Z., & He, M. (2026). Family-related factors associated with acceptance of advance care planning among older adults in China: a nationwide cross-sectional survey. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15416-y

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15416-y

Keywords: advance care planning, older adults, China, family communication, palliative care, end-of-life care, cross-sectional survey, gerontology, Family-related, factors, associated, acceptance