Dyadic attitudes on end-of-life care and advance care planning: a cross-sectional community study of older adults and family carers

Abstract Background Advance care planning seeks to align end-of-life care with patients’ preferences, but in Asian family-centred cultures the wishes of older adults may differ from what family carers assume, and dyadic evidence from community settings is scarce. This study examined end-of-life care preferences and attitudes towards advance care planning among older adults and their family carers in Thailand. Methods We conducted a cross-sectional dyadic survey of community-dwelling older adults (aged ≥ 60 years) and their primary family carers recruited from outpatient clinics and communities. A total of 480 dyads (960 individuals) completed structured questionnaires on end-of-life care preferences, general views on advance care planning, and item-level attitudes. Group differences were analysed descriptively and with matched-pair tests, and concordance in attitudes across 15 items was assessed using quadratic weighted kappa. Results Older adults placed greater importance than carers on full information about illness, involvement in decision-making, appointing a proxy, relief of distressing symptoms, avoiding burden on family, having family present, forgoing life-prolonging treatment with low chance of survival, remaining conscious, and dying at home. Both groups generally viewed advance care planning positively as a means to align care, reduce family conflict, and lessen decisional burden. However, a sizeable minority expressed death‑related anxiety, hopelessness, and discomfort about ACP, and many older adults (49.0%) were reluctant to engage while they felt they still had unresolved personal matters. Concordance in attitudes towards advance care planning was only slight to moderate across the 15 items (quadratic weighted kappa 0.205–0.477). Family carers suggested earlier ages for advance care planning for older people in general and for their relatives, yet were more likely to postpone advance care planning for themselves. Conclusions In this Thai, Asian collectivist context, advance care planning is broadly acceptable in principle, but family carers underestimate older adults’ end-of-life care preferences and show only modest concordance on key attitudes. Culturally sensitive, structured dyadic conversations embedded in routine care are needed to bridge these gaps and support dignified, preference-concordant end-of-life care. Trial registration NA.