Proactive end-of-life healthcare discussions are essential for ensuring that terminally ill or elderly patients receive care aligned with their personal values and preferences. Advance care planning involves structured communication among individuals, their family members, and multidisciplinary healthcare teams to establish clear treatment goals before acute clinical crises occur. However, despite known benefits such as reduced unwanted hospitalizations and improved family satisfaction, engagement in proactive care planning remains remarkably low in long-term care institutions. Family dynamics, emotional distress, and deeply rooted cultural beliefs often create significant obstacles when surrogate decision-makers face choices regarding life-sustaining interventions. Modern digital health tools, including automated messaging systems, interactive educational modules, and artificial intelligence chatbots, offer innovative opportunities to bridge these communication gaps. By delivering accessible, theory-grounded education directly to relatives, digital health solutions can increase readiness and confidence among family members. The ChatACP research initiative introduces a structured 10-day digital intervention designed to empower surrogate decision-makers, offering a scalable framework to enhance care planning in nursing home environments.

Understanding Cultural and Structural Barriers to Advance Care Planning

Implementing advance care planning within long-term care facilities involves navigating complex psychological, cultural, and organizational challenges. In many Asian and traditional family structures, care decisions for frail elderly relatives are predominantly delegated to adult children or surrogate family members. While family involvement ensures collective support, it frequently introduces reluctance to discuss terminal decline or end-of-life care preferences. Relatives often associate advance care discussions with emotional distress, filial neglect, or a premature surrender of hope. Furthermore, a widespread perception persists that aggressive medical interventions, such as prolonged mechanical ventilation or invasive cardiopulmonary resuscitation, represent the only acceptable demonstration of filial piety and high-quality medical care.

Traditional educational campaigns often rely on static paper pamphlets or brief clinical consultations during acute hospital admissions. Unfortunately, these passive approaches fail to address the underlying emotional ambivalence and readiness levels of surrogate decision-makers. Without tailored educational guidance, family members may feel overwhelmed by complex medical jargon, resulting in delayed decisions or aggressive interventions that contradict the resident's actual personal values. Overcoming these entrenched cultural barriers requires targeted, theory-driven empowerment strategies that guide families through progressive stages of psychological readiness while offering clear, practical guidance regarding end-of-life care choices.

Theoretical Framework and the Transtheoretical Model in Digital Interventions

To systematically address family hesitation, contemporary digital interventions utilize established behavioral theories, particularly the Transtheoretical Model of health behavior change. The Transtheoretical Model posits that individuals progress through distinct motivational stages—precontemplation, contemplation, preparation, action, and maintenance—when adopting complex decisions. Historically, advance care initiatives focused heavily on immediate documentation, such as executing advance directives or living wills, without evaluating whether family members possessed sufficient psychological readiness. Assessing family readiness allows healthcare providers to deliver customized educational content matched to the specific stage of the individual.

Integrating artificial intelligence and digital messaging within the Transtheoretical Model framework offers an adaptable medium for incremental learning. Digital tools provide non-judgmental, on-demand educational materials that relatives can process privately at their own pace. Infographics and short video demonstrations break down multi-step medical decisions into easily digestible concepts, removing intimidating administrative and clinical barriers. Interactive conversational agents further reinforce this process by offering instant answers to specific queries regarding medical terminology, legal instruments, and care options. By scaffolding knowledge according to individual readiness, theoretical frameworks ensure that surrogate decision-makers build genuine self-efficacy before participating in formal care planning discussions with medical teams.

The ChatACP Digital Intervention Protocol and Architecture

The ChatACP research protocol presents a novel 10-day digital health intervention specifically engineered to empower family members of nursing home residents in Hong Kong. Developed through an explanatory sequential mixed-methods design, the protocol evaluates the feasibility, acceptability, and preliminary efficacy of combining interactive digital tools with personalized nursing consultations. Eligible participants are randomized into two distinct cohorts: an intervention group receiving the ChatACP digital platform and a control group receiving standard written educational materials regarding care planning.

The intervention unfolds across two coordinated phases tailored to user progress. Phase 1 spans 10 consecutive days during which family members receive a structured sequence of daily educational infographics, short instructional videos, and access to a specialized, content-specific conversational chatbot. The chatbot provides real-time information regarding local advance care policies, decision-making frameworks, and palliative care options. Following completion of Phase 1, participants are assessed for their progress along the Transtheoretical Model continuum. Family members who have not yet advanced to the action stage are smoothly transitioned to Phase 2, which features a targeted, nurse-led telephone consultation. This secondary phase incorporates motivational interviewing techniques, allowing registered nurses to directly address personal anxieties, clarify residual doubts, and guide families toward meaningful decision-making.

Methodology, Pilot Trial Design, and Outcome Evaluation

The ChatACP pilot study utilizes a robust randomized controlled trial framework enrolling 60 eligible family members across six representative nursing home facilities. Primary evaluation criteria focus heavily on practical feasibility and user acceptability metrics. Researchers meticulously measure recruitment rates, participant retention, protocol fidelity, daily engagement levels, software usability, and safety outcomes. These quantitative feasibility markers are continually compared against predefined progress criteria to determine whether the intervention can be successfully scaled for larger clinical trials.

Secondary outcomes evaluate the preliminary efficacy of ChatACP in modifying family behaviors and attitudes over time. Assessments are conducted at baseline, immediately post-intervention, and at a 3-month follow-up milestone. Key secondary measures include family members' readiness to participate in care discussions, self-reported communication self-efficacy, knowledge acquisition, and actual completion rates of advance care planning activities. Analytical procedures employ generalized mixed-effects modeling to accommodate longitudinal repeated measures and account for potential facility-level clustering effects. Complementing the quantitative trial, a post-trial qualitative study gathers in-depth subjective feedback from participants and healthcare staff, offering critical insights into user experiences, cultural nuances, and potential workflow integration obstacles within institutional care settings.

Clinical Practice Implications for Nursing and Geriatric Care

The protocol for ChatACP highlights a transformative shift toward technology-assisted, family-centered communication in long-term geriatric care. For practicing nurses, geriatricians, and primary care physicians, integrating conversational artificial intelligence into routine workflow offers a promising solution to chronic clinical time constraints. Clinicians frequently struggle to allocate sufficient time for extended, multi-session counseling required to navigate complex family dynamics surrounding end-of-life choices. Automated messaging platforms handle preliminary background education, allowing nurses and physicians to focus their clinical expertise on high-value, nuanced consultations.

Furthermore, the ChatACP model emphasizes that empowering surrogate decision-makers directly improves patient-centered care for institutionalized older adults. When family members feel educated and supported, surrogate decision-making becomes less burdened by guilt, uncertainty, or panic during acute health declines. Bridging knowledge gaps prior to critical events fosters collaborative decision-making among families, care home staff, and attending physicians. Ultimately, structured digital interventions empower families to honor the personal dignity and autonomy of nursing home residents, paving the way for wider implementation across global geriatric healthcare systems.

Frequently Asked Questions

How does ChatACP assist family members who are hesitant to discuss end-of-life preferences?

ChatACP provides a non-confrontational digital environment where family members can explore educational infographics and ask questions to a specialized chatbot at their own pace. By utilizing the Transtheoretical Model, the intervention systematically builds background knowledge and addresses common emotional barriers. If families remain hesitant after the 10-day digital phase, a nurse-led consultation provides personalized motivational interviewing to address specific concerns gently.

What are the primary outcomes being measured in the ChatACP pilot study?

The ChatACP pilot study primary outcomes evaluate feasibility and acceptability, including recruitment efficiency, retention rates, protocol fidelity, platform usability, safety, and user engagement. Secondary outcomes assess clinical efficacy, focusing on family members' psychological readiness, communication confidence, knowledge acquisition, and formal completion of advance care planning documents evaluated at post-intervention and at 3-month follow-up assessments.

Why is nurse involvement incorporated alongside artificial intelligence in the ChatACP protocol?

Artificial intelligence chatbots excel at delivering standardized educational content and answering routine factual queries efficiently. However, sensitive end-of-life discussions often involve complex emotional distress, cultural beliefs, and family dynamics that require human empathy and expert clinical judgment. Nurse-led telephone consultations in Phase 2 ensure tailored support, integrating automated digital learning with compassionate professional nursing care.

Disclaimer: This content is for informational and educational purposes only and does not constitute medical advice, diagnosis, or treatment. Healthcare professionals should exercise their independent clinical judgment and refer to the latest local and national guidelines for clinical practice.

References

1. Wang T et al. Messaging and Chatbot-Assisted Nursing Consultation (ChatACP) to Empower Family Members of Residents of Nursing Homes on Advance Care Planning: Protocol for a Mixed Methods Pilot Study. JMIR Res Protoc. 2026 Aug 12. doi: 10.2196/94883. PMID: 42585665.
2. Lin CC et al. Digital technology and artificial intelligence in end-of-life care and advance care planning: A systematic review. J Med Internet Res. 2025;27:e54321.
3. World Health Organization. Palliative and end-of-life care guidelines for long-term care settings. Geneva: World Health Organization; 2025.