Abstract
BACKGROUND: Advance care planning implementation reveals complex tensions between ethical principles and cultural-specific moral frameworks. Within the Chinese healthcare context, medical decision-making operates within a unique ethical landscape shaped by Confucian values, yet systematic ACP promotion in this context remains limited. OBJECTIVE: This study aims to (1) develop a grounded theory of older adults' engagement with advance care planning in the Chinese context; (2) understand how participants navigate decision-making processes within China's cultural and healthcare systems. DESIGN: The investigation employed Charmaz's constructivist grounded theory methodology guided by Nie's framework of Chinese medical ethics through a three-stage approach across diverse geographical regions in China. PARTICIPANTS: Twenty-five participants (13 males/12 females) aged 60-95 years from representative regions of China. METHODS: Following Charmaz's constructivist grounded theory methodology, data collection progressed from pre-experimental convenience sampling (3 participants), to Stage 1 purposive sampling (12), and Stage 2 theoretical sampling (13) until saturation. Analysis employed concurrent interviews and constant comparative methods guided by Chinese medical ethical principles. RESULTS: The analysis produced the substantive theory "Navigating the Path to Planned Endings," encompassing three interconnected categories: Negotiating Death Discourse, The Locus of Decision, and Systemic Support Infrastructure. "The Locus of Decision" emerged as the core category where participants reconcile individual autonomy, filial obligations, and family harmony. CONCLUSIONS: The theoretical framework reveals complex ethical processes through which Chinese older adults engage with advance care planning, highlighting the crucial role of moral agency where traditional values and modern bioethical principles intersect. These findings necessitate culturally sensitive ACP implementation approaches acknowledging family roles while upholding principles of autonomy and justice.