Childlessness and advance care planning in midlife and late adulthood: A mixed-methods study in Singapore

Advance care planning (ACP) is critical for ensuring high-quality, cost-effective end-of-life care and is typically facilitated by spouses and adult children. Yet, the growing number of older adults without children has been overlooked in ACP research. This study employs a mixed-methods approach to examine ACP practices and perceptions among childless adults aged 50+ in Singapore, a rapidly aging society with one of the world's highest childlessness rates. Quantitative analyses draw on nationwide survey data (N = 1,500), complemented by interviews with childless respondents (N = 26). We examine multiple dimensions of ACP: formal ACP (e.g., living wills, Lasting Power of Attorney), informal ACP (discussions of end-of-life care with others), and two-pronged ACP (both documentation and discussion). Results show that childless adults, especially women, were more likely than parents to engage in ACP practices, often motivated by caregiving histories and a desire to reduce burdens on kin. Childless men were less inclined to plan than childless women, potentially reflecting social selection into childlessness, gendered orientations toward health behaviors, and weaker relational networks. Despite these differences, overall ACP engagement in Singapore remained modest. Qualitative evidence revealed broad, relational interpretations of ACP and highlighted various barriers, including difficulty appointing proxies, misconceptions about costs, and competing caregiving demands. As childlessness in late adulthood rises globally, understanding how individuals without children navigate end-of-life planning becomes increasingly important. Addressing barriers and leveraging social support structures can strengthen more inclusive and person-centered planning and ensure that older adults, regardless of their kin availability, are better prepared for end-of-life care.