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This qualitative descriptive study explored patient and family views on the most pertinent ACP outcomes. Semi-structured telephone/video-conferencing interviews were conducted with frail older persons (65+ years) and family or friend caregivers across Canada. Findings identify three desired outcomes: maximizing comfort and quality of life, strengthening confidence in decision-making to reassure families, and maintaining autonomy so individuals can live and die according to their terms.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/what-do-older-adults-with-frailty-and-their-caregivers-want-from-advance-care-planning-discussions-descriptive-qualitative-study/461157/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/what-do-older-adults-with-frailty-and-their-caregivers-want-from-advance-care-planning-discussions-descriptive-qualitative-study/461157.png","ImageObject",300,407,{"name":92,"@type":93},"Adam","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":39},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What outcomes do older adults with frailty and their caregivers want from ACP discussions?","Question",{"text":112,"@type":113},"Participants described three desired outcomes: maximizing comfort and quality of life, enhancing confidence in decision-making to reassure families, and maintaining autonomy so people can live and die on their own terms.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How was the study conducted?",{"text":117,"@type":113},"The study used semi-structured telephone/video-conferencing interviews with older persons with frailty (65+ years) and their family or friend caregivers across Canada.",{"name":119,"@type":110,"acceptedAnswer":120},"Why is measuring outcomes in ACP considered challenging?",{"text":121,"@type":113},"Systematic reviews show inconsistent findings, partly because ACP outcome measurement lacks consistency across programs and evaluations.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},461157,1790913805,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":39,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":52,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":144,"preview_page_count":4},1374404737137,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Article  \nWhat Do Older Adults with Frailty and Their Caregivers Want from Advance Care Planning Discussions? A Descriptive Qualitative Study  \nRobin Urquhart 1,2, *, Cynthia Kendell 3, Jessica Vickery 1 and Elias Hirsch 2  \n1 Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS B3H 1V7, Canada; [jvickery@dal.ca](jvickery@dal.ca)  \n2 Department of Surgery, Nova Scotia Health Authority, Halifax, NS B3H 2Y9, Canada; [eliashirsch11@gmail.com](eliashirsch11@gmail.com)  \n3 Department of Medicine, Dalhousie University, Halifax, NS B3H 2Y9, Canada; [cynthia.kendell@nshealth.ca](cynthia.kendell@nshealth.ca)  \n* Correspondence: [robin.urquhart@nshealth.ca](robin.urquhart@nshealth.ca); Tel.: +902-473-8245  \nAbstract  \nIntroduction: Advance care planning (ACP) may facilitate person-centered, goal-concordant care for this population. However, we know little about what older adults expect from ACP discussions (that is, the outcomes they expect or desire) . We sought to explore patient and family views on the outcomes they consider most pertinent to ACP discussions for older adults living with frailty. Methods: This qualitative descriptive study used semi-structured telephone/video-conferencing interviews with older persons with frailty (65+ years) and their family/friend caregivers from across Canada. All interviews took place in person or via telephone or Zoom with healthcare professionals, depending on the participant’spreference, and were conducted by a researcher with experience in qualitative methods. Data analysis involved coding, grouping, detailing, and comparing the data, using techniques commonly employed in descriptive qualitative research. Results: Nine participants  \ntook part in this study: two were individuals living with frailty, and seven were caregivers  \nof persons with frailty. They described three desired outcomes of ACP: (1) maximizing comfort and quality-of-life; (2) enhancing confidence in decision-making, which would heighten families’ level of reassurance as their loved one’s function and health status declines; and (3) maintaining autonomy so that people can live and die on their own terms. Conclusions: Ultimately, research and clinical care should tailor their ACP initiatives and evaluation metrics to align with what patients and families deem most important. The outcomes described by participants of this study should be further investigated and refined in future research.  \nAcademic Editor: Rosario Caruso  \nReceived: 11 October 2025  \nRevised: 16 December 2025  \nAccepted: 17 December 2025  \nPublished: 19 December 2025  \nCopyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license.  \nKeywords: advance care planning; frailty; caregivers; quality of life; decision-making; autonomy  \n1. Introduction  \nFrom a health system and societal perspective, the increasing prevalence of frailty may be the most concerning manifestation of population aging [1] . Frailty is highly prevalent among older, community-dwelling adults worldwide: a recent pooled analysis of 46 observational studies from 28 countries suggests that 1 in 6 community-dwelling older adults are frail [2] . In Canada, 24% of community-dwelling adults age 65 years and older are frail, with another 32% at high risk of becoming frail [3] . Frailty is associated with  \ngreater use of health care services [4] and is the leading pathway to death (24%) amongst older adults, more common than organ failure (21%), cancer (19%), or dementia (14%) [5,6] .  \nPersons with frailty deserve person-centered, goal-concordant care as they near the end of life. Research demonstrates this is not the reality for many Canadians. For example, as older adults with frailty experience considerable loss of capacity in later life, most report their desire for treatment aimed at maximizing quality of life rather than pro","cbCaivse5DONEwNW","https://ap.wps.com/l/cbCaivse5DONEwNW","pdf",205992,"English","# Abstract\n# Introduction\n## Advance care planning and expected outcomes\n## Frailty prevalence and end-of-life care needs\n## Definition of ACP and challenges in outcome measurement\n# Objective","[{\"question\":\"What outcomes do older adults with frailty and their caregivers want from ACP discussions?\",\"answer\":\"Participants described three desired outcomes: maximizing comfort and quality of life, enhancing confidence in decision-making to reassure families, and maintaining autonomy so people can live and die on their own terms.\"},{\"question\":\"How was the study conducted?\",\"answer\":\"The study used semi-structured telephone/video-conferencing interviews with older persons with frailty (65+ years) and their family or friend caregivers across Canada.\"},{\"question\":\"Why is measuring outcomes in ACP considered challenging?\",\"answer\":\"Systematic reviews show inconsistent findings, partly because ACP outcome measurement lacks consistency across programs and evaluations.\"}]","What Do Older Adults with Frailty and Their Caregivers Want from Advance Care Planning Discussions? - Descriptive Qualitative Study | PDF",1790760765,25]