Abstract
BACKGROUND: Older adults with frailty are at risk of rapid health decline and poor outcomes, including end of life. While advance care planning (ACP) can support person-centred care, how to assess and support older adults' ACP readiness remains unclear. Health and social care practitioners, and family caregivers, are often main providers of care, but their role in ACP is poorly understood. OBJECTIVES: To understand the readiness of older adults with frailty to engage in ACP from the perspectives of older adults, family caregivers, and health and social care practitioners. DESIGN: An exploratory qualitative interview study informed by the COM-B system (individual-level behaviour change) and the Ecological Systems Theory (system-level influences). METHODS: Semi-structured qualitative interviews with older adults (mild to moderate frailty), unpaid family caregivers, and health and social care practitioners in Japan. The topic guide was informed by the theoretical frameworks, exploring individual- and system-level factors influencing readiness. Reflexive thematic analysis was conducted to generate themes within and across the participant data sets. RESULTS: Twenty-nine interviews were conducted with 32 participants: older adults (n = 10), caregivers (n = 6), and health (n = 6) and social care practitioners (n = 10). Three themes were generated: (1) 'Leave decision-making to family' and Bridging family dynamics - older adults delegate decisions, practitioners navigate complex family relationships; (2) 'ACP is not part of our role': Diverging role expectations among practitioners, and hesitation to engage in ACP - differing perceived practitioners responsibilities limit willingness to initiate ACP; (3) Transitional period: Social norms around death and dying, family structures, and health and social care systems - shifts in systemic and social aspects shape ACP readiness. DISCUSSION: ACP readiness among this population is not solely an individual decision but is shaped by relationships, systemic, and societal factors. Enhancing ACP readiness requires a system-wide approach that incorporates family involvement and interdisciplinary collaboration and is adapted to the local context. TRIAL REGISTRATION: Not applicable.