When Advance Care Planning Is Not Yet an Option: Preconditions for Participation and the Relational Work of Nursing

Advance care planning (ACP) non-initiation is commonly attributed to information deficits or low motivation. I argue here that a more fundamental barrier exists: ACP may not yet have become cognitively and relationally available as a meaningful option within a person's everyday horizon. Drawing on a concept-oriented review of the theoretical and empirical literature, I develop a participatory framework built on four linked preconditions. First, decision readiness describes the pre-decisional state, in which future care becomes sufficiently thinkable to enter dialogue. Second, the cognitive repertoire reconceptualises ACP learning as the formation of latent resources -values, questions and interpretive frames-that can be activated when life circumstances make future care salient. Third, self-disclosure highlights that, even when internal readiness exists, participation depends on relational and emotional conditions that make concerns speakable. Fourth, supportive nudging describes the deliberate design of environmental and relational conditions that allow already-existing concerns to surface without compromising autonomy. Altogether, these preconditions suggest that ACP non-initiation is better understood as a problem of option accessibility than one of information transfer. This reframing has direct implications for how ACP interventions are designed and evaluated and extends to the broader questions of patient and public participation in future-oriented care.