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The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials

Lin, Cheng-Pei; Evans, Catherine J.; Koffman, Jonathan; Armes, Jo; Murtagh, Fliss E.M.; Harding, Richard


Cheng-Pei Lin

Catherine J. Evans

Jonathan Koffman

Jo Armes

Richard Harding



Background: No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced
cancer, and the mechanisms of action in relation to the intended outcomes.
Aim: To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the
components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes.
Design: A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative
synthesis was used for data analysis.
Data sources: The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey
with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with
advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality
Results: Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which
advance care planning improved outcomes comprised (1) increasing patients’ knowledge of end-of-life care, (2) strengthening
patients’ autonomous motivation, (3) building patients’ competence to undertake end-of-life discussions and (4) enhancing shared
decision-making in a trustful relationship. Samples were largely highly educated Caucasian.
Conclusion: The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they
identify the individual behavioural change. Strengthening patients’ motivation and competence in participating advance care planning
discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and
ethnicities in non-Western countries should be a research priority.


Lin, C.-P., Evans, C. J., Koffman, J., Armes, J., Murtagh, F. E., & Harding, R. (2019). The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials. Palliative medicine, 33(1), 5-23.

Journal Article Type Review
Acceptance Date Nov 7, 2018
Online Publication Date Oct 26, 2018
Publication Date Jan 1, 2019
Deposit Date Nov 27, 2018
Publicly Available Date Nov 27, 2018
Journal Palliative Medicine
Print ISSN 0269-2163
Publisher SAGE Publications
Peer Reviewed Peer Reviewed
Volume 33
Issue 1
Pages 5-23
Keywords Anesthesiology and Pain Medicine; General Medicine
Public URL
Publisher URL
Contract Date Nov 27, 2018


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© The Author(s) 2018

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (

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