Multilevel factors related to advance care planning engagement among Korean older adults: An ecological approach

Advance care planning (ACP) supports dignified end-of-life care by reducing decision-making burdens, minimizing unwanted treatment, and lowering costs. Despite these benefits, ACP engagement among Korean older adults remains limited. Most studies focused on individual factors, highlighting the need to examine interpersonal and community influences. This study assessed ACP engagement among Korean older adults and analyzed multilevel associations of intrapersonal, interpersonal, and community factors using an ecological model.

A cross-sectional observational study was conducted. This survey included 490 community-dwelling older adults nested within 30 regions, using region-based quota sampling. ACP engagement was measured using the 34-item Advance Care Planning Engagement Survey, validated in Korean. Independent variables included intrapersonal (demographics, health, attitudes toward death, eHealth literacy); interpersonal (household type, family cohesion, social networks); and community (residential regions, resources) factors. Linear mixed-effects modeling with restricted maximum likelihood estimation was used to identify factors associated with ACP engagement.

The mean ACP engagement score was 2.63 ± 0.76 on a 5-point scale, lowest with quality of life-health situations and flexibility for surrogate decision-makers. Higher ACP engagement was associated with more diagnoses (β=0.24, p<.001), positive attitudes toward death (β=-0.03, p=.010), higher eHealth literacy (β=0.03, p<.001), stronger family cohesion (β=0.02, p=.013), daily natural support interactions (β=0.16, p=.041), and more social welfare facilities (β=0.05, p=.043).

A comprehensive, multilevel approach integrating education, family discussions, healthcare system, and accessible community programs is essential to promote ACP in Korea. Entrenching ACP in end-of-life care requires its integration into routine healthcare, institutional support, and healthcare provider training.