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​Research and Knowledge Transfer Projects 

In recent years, many studies and health‑promotion initiatives have demonstrated the feasibility and acceptability of Advance Care Planning (ACP) within Chinese communities. These programmes empower the public to understand potential treatment and care options. Findings of these project evaluations consistently show that ACP brings positive impacts at the individual, family, and societal levels.

"Let Me Talk" ACP programme 

"Let Me Talk" ACP program

This is the first ACP programme designed specifically for Chinese cultural contexts. Since 2005, ACP has been conducted with older adults living in residential care homes in Hong Kong, using a storytelling approach to guide them through the process:

  • ‘My Story’: Reflecting on their life experiences

  • ‘My Views’: Clarifying their perspectives on life

  • ‘My Wishes’: Planning for the final stage of life

 

This approach has since been adopted or used as a reference in Mainland China and other regions across the Asia‑Pacific.

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"Have a Say" ACP programme

"Have a Say" ACP Programme

Under the framework of the ‘Let Me Talk’ project, the core concepts have been extended to individuals with early‑stage dementia and their families. The initiative addresses not only end‑of‑life care, but also long‑term care needs, helping them prepare in advance.

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The planning process enables individuals and their families to gain an early understanding of the potential impacts of the condition. While the person still retains decision‑making capacity, they are encouraged to discuss their preferences for future care with their families. This helps prevent disagreements among family members when they may later need to make care decisions on the person’s behalf.

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"My Passport"

「My Nursing Care Plan」

This project is an extension of the ‘My Way’ initiative, promoting the concept of ACP within primary care settings. Its target audience is no longer limited to older adults or individuals with terminal or long‑term illnesses; instead, it aims to help a broader population understand how they can plan ahead for their own or their significant others' care.

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The project also provides training on ACP for health and social care professionals, equipping them with greater confidence to initiate such conversations and supporting the development of related services.

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Tools for ACP

Making decisions about care can be challenging, as it involves a wide range of medical, social and legal considerations. Planning for future care adds another layer of complexity. To help the public better understand the possible benefits and limitations of different care options, various educational and informational tools have been developed locally—including micro-movie, board game, and immersive virtual‑reality videos—to provide a more vivid illustration of what each option entails.

Micro-Movies

Two films are developed based on scenarios commonly encountered in clinical practice. The stories depict the emotional struggles and inner conflicts experienced by family members when making care decisions on behalf of a seriously ill patient. It aims to help viewers understand that ACP is not only about an individual’s well‑being, but also about the harmony of the family and the emotional burden they may carry. Through the film’s narrative, we hope to raise awareness of the importance of early planning so as to lessen the decision‑making burden that significant others may face in the future.

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YouTube Link

Board game

“The Five Flavours in a Grocery Store" is the first co‑designed board game created for life education within the Chinese community. The project was jointly developed by The Nethersole School of Nursing of the Faculty of Medicine, CUHK and Tung Wah Group of Hospitals. Supported by empirical evidence, the game has been shown to encourage players to actively reflect on their own views about life and death, while the interactions during gameplay also help them understand others’ perspectives toward end‑of‑life care.

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Immersive Virtual Reality Video 

Many people are unfamiliar with end‑of‑life care, making it difficult for them to appreciate the importance of ACP. To address this, the team at The Nethersole School of Nursing, Faculty of Medicine, CUHK, produced an immersive video that depicts—through the first‑person perspective of a patient—the experience of being unable to participate in one’s own treatment decisions. Designed for educational use, the video aims to enhance healthcare students’ empathy toward patients. Evaluation findings show that the video prompted students to reflect on their caring attitudes and the impacts of treatments on  the physical and psychological wellbeing of patients.

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Relevant information 

There are many free online resources that introduce the concepts of ACP and end‑of‑life care, and support individuals in considering the various aspects involved in the planning process. Below are some examples for reference:

Relevant literature

The above initiatives have been published in various international refereed journals. Below are some of the major works:

Effects of different ACP programmes

Communication modes

  • Chan, H. Y. L., Leung, D. Y., Lam, P. T., Ko, P. P., Lam, R. W., & Chan, K. S. (2025). Effect of motivational interviewing to promote advance care planning among palliative care patients in ambulatory care setting: a randomized controlled trial. BMC Palliative Care, 24(1), 72. https://doi.org/10.1186/s12904-025-01692-8

  • Leung, D. Y. P., Chung, J. O. K., Chan, H. Y. L., Lo, R. S. K., Li, J., Lam, P. T., Ng, N. H. Y. (2024). Effects of a structured, family-supported, and patient-centred advance care planning on end-of-life decision making among palliative care patients and their family members: Protocol of a randomised controlled trial. BMC Palliative Care, https://doi.org/10.1186/s12904-024-01588-z

  • ​Lai J. C. T., Chan, H. Y. L. (2022). A video decision aid for advance care planning among community-dwelling older Chinese adults: A cluster randomized controlled trial. Journal of Palliative Medicine. http://doi.org/10.1089/jpm.2022.0269

  • Deng, R., Zhang, J., Chen, L., Miao, J., Duan, J., Qiu, Y., Leung, D., Chan, H. Y. L., & Lee, D. T. (2020). The effectiveness of a modified advance care planning programme. Nursing Ethics, 27(7). 1569-1586. doi: 10.1177/0969733020922893

  • ​Leung, D.Y.P., Chan, H. Y. L., Yau, S.Z.M., Chiu, P.K.C., Tang, F.W.K.., Kwan, J.S.K. (2019). A video-supported nurse-led advance care planning on end-of-life decision making among frail geriatric patients: Protocol for a randomized controlled trial. Journal of Advanced Nursing, 75(6), 1360-1369. https://doi.org/10.1111/jan.13959

  • ​Chan, H. Y. L., Ng, J.S.C., Chan, K.S., Chan, L.N., Ko, P.S., Leung, D.Y.P., Lee, I.F.K., Lee, D.T.F., Chan, C.W.H. (2018). Effects of a nurse-led post-discharge advance care planning programme for community-dwelling patients nearing the end of life and their family members: A randomised controlled trial. International Journal of Nursing Studies, 87, 26-33.

  • Ng, A. M. F., Leung, D. Y. P., Chan, H. Y. L. (2015). Effects of advance care planning on knowledge, behaviour, and well-being of older adults: A systematic review. Asian Journal of Gerontology and Geriatrics, 10.

  • Chan, H. Y. L. & Pang, S. M. C. (2010). Let Me Talk – an advance care planning programme for frail nursing home residents. Journal of Clinical Nursing, 19, 3073-3084.

Gamification

  • Liu, L., Chan, H. Y. L., Zhao, Y. Y., Xiong, G. J., Qing, M. B., Gu, C., & Wang, Y. (2025). Effects of a Game on Advance Care Planning Engagement in Older Adults: A Randomised Controlled Trial. Journal of Pain and Symptom Management.  https://doi.org/10.1016/j.jpainsymman.2025.02.016

  • Liu, L., Wang, Y., Ho, T. C., Li, M. M., Cheung, E. W., Chow, R. S., Gu, C., & Chan, H. Y. L. (2024). Co-designing a Culturally-Sensitive Theory-Driven Advance Care Planning Game with Chinese Older Adults and Healthcare Providers. Palliative Medicine. https://doi.org/10.1177/02692163231222776

  • Liu, L., Chan, H. Y., Ho, T. C., Chow, R. S., Li, M. M., Cheung, E. W., Gu, C., & Wang, Y. (2023). A serious game for engaging older adults in end-of-life care discussion: A mixed method study. Patient Education and Counseling, 113, 107787. https://doi.org/10.1016/j.pec.2023.107787

  • Liu, L., Zhao, Y.Y., Yang, C., & Chan, H. Y. L. (2021). Gamification for promoting advance care planning: A mixed-method systematic review and meta-analysis. Palliative Medicine, 35(6), 1005-1009.

For persons with
dementia

  • Yeung, C. Y., & Chan, H. Y. L. (2025). Promoting advance care planning in people with early dementia and their family caregivers. Hong Kong Medical Journal, 31 S3(3), 23–26

  • Yeung, C. C. Y., Ho, K. H. M., & Chan, H. Y. L. (2023). A dyadic advance care planning intervention for people with early-stage dementia and their family caregivers in a community care setting: A feasibility trial. BMC Geriatrics, https://doi.org/10.1186/s12877-023-03815-3

​Tools for evaluating ACP

Staff preparedness

  • Yuen, J. K., Chan, H. Y. L., Chen, T. W. T., Chu, S. T., Kwok, A. O. L., Leung, D. Y. P., Gill, H. S., Tsang, K. W., Tse, D. M. W., Yap, D. Y. H., Yip, T., & Arnold, R. M. (2025). Cross-cultural adaptation and validation of the Chinese version of the quality of communication questionnaire. BMC Palliative Care, 24(1), 140. https://doi.org/10.1186/s12904-025-01786-3

  • ​Chan H. Y. L., Chun GKM, Man CW, Leung EMF. (2018). Staff preparedness for providing palliative and end-of-life care in long-term care homes: Instrument development and validation. Geriatric and Gerontology International, 18(5), 745-749.

Public readiness

  • ​Liu, L., Zhao, Y.Y., Zhang, L.H., Chan, H. Y. L. (2020). Measuring self-efficacy and readiness for advance care planning in Chinese older adults. Journal of Pain and Symptom Management, 60(3):622-629. doi: 10.1016/j.jpainsymman.2020.06.013​

ACP Training

  • Chan, C. W. H., Ng, N. H. Y., Chan, H. Y. L., Choi, K. C., Chow, K. M., Kwan, C. W. M., Robinson, J., & Tse, M. (2025). The effects of a Multi-media Experiential Advance Care Planning (MEACP) training programme for nurses in the acute care settings: A cluster randomised controlled trial. Nurse Education in Practice, 86, https://doi.org/10.1016/j.nepr.2025.104428

  • Chan, C. W., Ng, N. H., Chan, H. Y., Choi, K. C., Chow, K. M., Kwan, C. W., Robinson, J., & Tse, M. (2025). Development and pilot testing of a theory-driven and evidence-based advance care planning training programme for nurses in acute care settings. European Journal of Oncology Nursing, 74, https://doi.org/10.1016/j.ejon.2024.102760

  • Chan, H. Y. L., Kwok, A.O.L., Yuen, K.K., Au, D. K.S., Yuen, J.K.Y. (2020). Association between training experience and readiness for advance care planning among healthcare professionals: A cross sectional study. BMC Medical Education. https://doi.org/10.1186/s12909-020-02347-3

  • Chan, C.W.H., Ng, N.H.Y., Chan, H. Y. L. et al. (2019). A systematic review of the effects of advance care planning facilitators training programs. BMC Health Service and Research, 19, 362. https://doi.org/10.1186/s12913-019-4192

​Factors related to ACP implementation

  • Mori, M., Chan, H. Y. L., Lin, C. P., Kim, S. H., Ng Han Lip, R., Martina, D., Yuen, K. K., Cheng, S. Y., Takenouchi, S., Suh, S. Y., Menon, S., Kim, J., Chen, P. J., Iwata, F., Tashiro, S., Kwok, O. L. A., Peng, J. K., Huang, H. L., Morita, T., Korfage, I. J., … Kizawa, Y. (2024). Definition and recommendations of advance care planning: A Delphi study in five Asian sectors. Palliative medicine, 2692163241284088. Advance online publication. https://doi.org/10.1177/02692163241284088

  • Lin, C. P., Peng, J.K., Hsieh, W.T., Martina, D., Mori, M., Takenouchi, S., Chan, H.Y.L., Suh, S.Y., Kim, S.H., Yuen, K.K., Kizawa, Y., Cheng, S.Y. (2023). Improving Access to Advance Care Planning in Current and Future Public Health Emergencies: International Challenges and Recommendations. Journal of Palliative Medicine, 26(4), 462-463.http://doi.org/10.1089/jpm.2023.0030

  • Chan, C. W. H., Chen, Y. F., & Chan, H. Y. L. (2023). Advance Care Planning in Hong Kong. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen, 180, 90–93. https://doi.org/10.1016/j.zefq.2023.05.015

  • Cheng, S. Y., Lin, C.P., Chan, H. Y. L., Martina, D., Mori, M., Kim, S., Ng, R. (2020). Advance care planning in Asian culture. Japanese Journal of Clinical Oncology, 50(9), 976-989. doi.org/10.1093/jjco/hyaa131

  • Chan, H. Y. L., Lee, D.T.F., Woo, J. (2020). Diagnosing gaps in the development of palliative and end-of-life care: A qualitative exploratory study. International Journal of Environmental Research and Public Health, 17, 151, doi: 10.3390/ijerph17010151

  • Ngan, O.M.Y., Bergstresser, S.M., Sanip, S., Emdadul Haque, A.T.M., Chan, H. Y. L., Au, D.K.S. (2019). Cultural considerations in forgoing enteral tube-feeding: A comparison between the Hong Kong Chinese, North American, and Malaysian Islamic patients with advanced dementia at the end-of-life. Developing World Bioethics, DOI: 10.1111/dewb.12239

  • Lin, C.P., Cheng, S.Y., Mori, M., Yeon, S.S., Chan, H. Y. L. Diah, M., ..et al.(2019). Taipei Declaration on Advance Care Planning: A cultural adaptation of end of life care discussion. Journal of Palliative Medicine, 22:1175-1177

  • Woo, J., Chan, H. Y. L., Chong, A. M. L., Zou, M., Chung, R. Y., & Kwok, T. (2015). Medical Ethical Principles may Drive Improvement of Quality of Dying in Hong Kong. Journal of Palliative Care and Medicine. http://dx.doi.org/10.4172/2165-7386.1000227

  • Nan, K., Lai, R. Y. K., Chan, H. Y. L. (2022). Decision control preference for end-of-life care among older adults. Geriatrics and Gerontology International. doi: 10.1111/ggi.14540

  • Wan, Z.; Chan, H. Y. L.; Chiu, P.K.C.; Lo, R.S.K.; Cheng, H.L.; Leung, D.Y.P. (2022). Experiences of Older Adults with Frailty Not Completing an Advance Directive: A Qualitative Study of ACP Conversations. Int. J. Environ. Res. Public Health 2022, 19, 5358. https://doi.org/10.3390/ijerph19095358

  • ​Chan, C.W.H., Wong, M.M.H., Choi, K.C., Chan, H. Y. L., Chow, A.Y.M., Lo, R.S.K., Sham, M.M.K. (2019). What patients, families, health professionals and hospital volunteers told us about advance directives? Asia Pacific Journal of Oncology Nursing, 6, 72-77.

  • Chan, C.W.H., Wong, M.M.H., Choi, K.C., Chan, H. Y. L., Chow, A.Y.M., Lo, R.S.K., Sham, M.M.K. (2019). Prevalence, Perception and Predictors of Advance Directives among Hong Kong Chinese: A Population-based Survey. International Journal of Environmental Research and Public Health, 16(3), 365.

  • Chan, H. Y. L. & Pang, S. M. C. (2011). Readiness of Chinese frail old age home residents to end-of-life care decision making. Journal of Clinical Nursing, 20, 1454-1461.

  • Chan, H. Y. L. & Pang, S. M. C. (2007). Quality of life concerns and end-of-life care preferences of aged persons in long-term care facilities. Journal of Clinical Nursing, 16, 2158-2166.

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