{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,10]],"date-time":"2026-04-10T17:45:22Z","timestamp":1775843122889,"version":"3.50.1"},"reference-count":44,"publisher":"Wiley","issue":"5","license":[{"start":{"date-parts":[[2025,12,24]],"date-time":"2025-12-24T00:00:00Z","timestamp":1766534400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2025,12,24]],"date-time":"2025-12-24T00:00:00Z","timestamp":1766534400000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/501100010983","name":"Health Research Fund of Central Denmark Region","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100010983","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal of Clinical Nursing"],"published-print":{"date-parts":[[2026,5]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Older adults often experience unplanned hospital admissions at the end of life, which may conflict with their wish to remain at home. Advance care planning (ACP) can help align care with patient preferences, but timely discussions and documentation are often lacking. Effective communication across healthcare settings is therefore essential.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Aim<\/jats:title>\n                    <jats:p>To explore how ACP is delivered for community\u2010dwelling older adults, focusing on intervention components, communication during care transitions and related barriers and facilitators.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A scoping review conducted according to Joanna Briggs Institute methodology and reported according to the Preferred Reporting Items for Systematic Reviews and Meta\u2010Analyses extension for Scoping Reviews (PRISMA\u2010ScR) guidelines.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We systematically searched six databases (PubMed, Embase, CINAHL, PsycINFO, Scopus and Web of Science) on 7 April 2025 for peer\u2010reviewed primary studies on ACP interventions for community\u2010dwelling older adults during healthcare transitions. Data were extracted using a structured table.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Sixteen studies from seven countries (2016\u20132024) were included, with most conducted in the United States. ACP interventions typically involved healthcare professional education, structured documentation and coordination across settings. Communication strategies included written records, discharge summaries, telephone calls, face\u2010to\u2010face meetings and electronic systems. Key facilitators were timely patient identification, GP involvement, clear role distribution and use of existing clinical structures. Barriers included time constraints, unclear responsibilities, fragmented communication, insufficient training and emotional reluctance. ACP was often deprioritised due to acute care episodes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>ACP for community\u2010dwelling older adults is a complex intervention challenged by structural, organisational and relational barriers. Future research should explore sustainable, context\u2010sensitive ACP models that emphasise long\u2010term integration, patient experiences and diverse care settings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient or Public Contribution<\/jats:title>\n                    <jats:p>No patient or public contribution.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jocn.70185","type":"journal-article","created":{"date-parts":[[2025,12,24]],"date-time":"2025-12-24T09:15:16Z","timestamp":1766567716000},"page":"1979-1993","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Advance Care Planning During Healthcare Transitions for Community\u2010Dwelling Older Adults in Their End of Life: A Scoping 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