Authors: (including presenting author): :
Lam K(1), Lum C(3),Tong C(3), Chan F(3),Leung K(2),Cheng W(1),Lai D(3), Woo J(3)
Affiliation: :
(1) Department of Medicine & Geriatrics, Shatin Hospital (2) Health Resource Center, Bradbury Hospice/Shatin Cheshire Home/ Shatin Hospital (3) Institute of Ageing, The Chinese University of Hong Kong
Keyword 1: :
Empowering Patients and Families
Keyword 2: :
Advance Care Planning
Keyword 3: :
Advance Directive
Keyword 4: :
Medical–Social Collaboration
Keyword 5: :
End of Life Care
Keyword 6: :
Geriatric Service
Introduction: :
Advance Care Planning (ACP) and Advance Medical Directives (AMD) are central to patient-centred end-of-life (EOL) care. In Hong Kong, ACP initiatives have largely focused on outpatient or community settings, with limited structured engagement of patients and families during acute hospitalisation. To address this gap, we developed a collaborative medical–social program that proactively enrols in patients and their families in ACP sharing and discussion during hospital admission for acute medical conditions. To our knowledge, this is the first structured program in Hong Kong to systematically enrol family members of geriatric in patients during acute hospitalisation for ACP sharing and discussion through coordinated medical–social collaboration.**
Objectives: :
This program aimed to strengthen interdisciplinary collaboration, engage patients and families during acute in-patient care, and empower informed ACP/AMD discussions through an integrated hospital–community approach.
Methodology: :
Since March 2021, a multifaceted program has been implemented through close collaboration among geriatricians, nurses, social workers, academic partners, and community health resource centers. Family members of in-patients admitted to geriatric wards for acute illnesses were systematically invited to participate in ACP sharing sessions during hospitalisation, supported by coordinated medical and social care input. Program components included: 1) bi-monthly small group ACP sharing sessions delivered in a hybrid face-to-face and Zoom format; 2) focused community talks on ACP, AMD, life-sustaining treatments (LSTs), and EOL care; 3) coordinated follow-up support for ACP communication and documentation; and 4) a qualitative telephone interview study evaluating participant experiences. The program emphasised shared decision-making and seamless coordination between medical and social care teams.
Result & Outcome: :
Results: From March 2021 to August 2025, 35 bi-monthly sharing sessions engaged 239 participants, mainly family members of 131 hospitalised geriatric patients. Five focused community talks reached an additional 380 participants. Overall, 619 participants were reached across in-patient and community settings, demonstrating substantial service coverage achieved through collaborative teamwork. Evaluation surveys (n=254) showed improved knowledge of ACP, AMD and LSTs, high satisfaction, and increased willingness to discuss EOL care. Eight patients completed ACP documentation with structured medical–social support. Qualitative interviews (n=23) highlighted that early ACP engagement during hospitalisation facilitated timely family communication and informed decision making. Findings have been disseminated through peer reviewed publication and conference presentations. Conclusion: This first-of-its-kind in-patient ACP enrolment program in Hong Kong demonstrates how medical–social collaboration can shift ACP discussions upstream into acute hospital care. The model is feasible, scalable, and highly relevant to Hospital Authority settings, offering a practical approach to strengthening patient and carer-centred EOL care.
