Community-Based Interventions for Initiating Early End-of-Life Conversations in Nonterminally Ill Adults: A Systematic Review.

Background: End-of-life (EOL) conversations offer individuals opportunities for consideration of future treatment options with accordance to their values and wishes, helping maintain autonomy and dignity in the eventual dying process. While there exists multiple reports in the international literature focusing on community-based interventions for initiating early advanced care planning (ACP) conversations and EOL planning behaviors in non-terminally ill adults, the effects of these interventions are poorly understood. Objectives: We conducted a systematic review and meta-analysis to provide a comprehensive summary of community-based interventions for the initiation of early ACP conversations and EOL planning behaviors that may aid other countries and societies in adopting such implementations. Search Methods: A total of 30,869 abstracts were identified from CINAHL, Cochrane Central Register of Controlled Trials, Embase, PsycINFO and PubMed from their respective dates of inception to 20 July 2025, of which 71 articles were included in the final analysis. Selection Criteria: The population of interest were non-terminally ill adults above the age of 18 who were residing in the community at the time of study. The intervention of interest was any community-based intervention with the objective of promoting or educating on EOL and ACP related topics. The comparator was any ongoing education or outreach on EOL and ACP in the community or no intervention at all. The outcome was (1) rate of completion of EOL and ACP-related behaviors and (2) self-reported scores of knowledge, attitudes and perceptions of EOL and ACP. Data Collection and Analysis: Two investigators independently extracted data for each study, pertaining to the study design, intervention design, baseline characteristics, EOL and ACP-related knowledge, attitude. The quality of studies was appraised in reference to the National Institute for Health and Care Excellence checklist. A meta-analysis of standardized mean difference (SMD) was conducted to assess the effectiveness of interventions in improving (1) uptake of EOL and ACP-related behaviors and (2) knowledge, attitudes and perceptions (KAP) towards EOL and ACP. Main Results: 83 studies consisting of interventions using workshops, 1-to-1 counselling, discussion groups, modified AD, complex methods, distribution of printed or online materials, were included in this study. Community-based EOL interventions were significantly associated with carrying out EOL or ACP-related behaviors (n = 71,489 participants in 19 studies, RR = 2.24, 95% CI: 1.42 to 3.53, I Authors’ Conclusions: Community-based interventions were shown to be effective in improving uptake of EOL and ACP-related behaviors and perceptions towards EOL and ACP amongst the nonterminally ill. Further studies investigating interventions for promotion of EOL and ACP should consider appropriate right-siting in the community and co-creation with key community figures to improve contextualization and generalizabilty.