Negotiated Advance Care Planning in Contexts Without Legal Mandates: A Concept Derivation

Abstract Background Advance care planning is widely defined as an iterative, values-based process that involves communication, documentation, and periodic review. However, in settings without robust statutory enforceability, the authority of plans often depends on relational and organisational governance, and the “negotiated” dimension of ACP remains conceptually unstable. We therefore aimed to derive and operationalise the concept of negotiated ACP for non-statutory or weakly protected contexts. Methods We conducted an integrative review to extract definitional statements and attributes relevant to negotiated ACP, searching major English-language databases from inception to 5 January 2026 (Scopus, PubMed, CINAHL, Web of Science) and major Chinese databases (CNKI, WanFang, SinoMed), supplemented by grey literature. Two reviewers independently screened and selected studies using PRISMA procedures, then charted and synthesised conceptual content in a narrative synthesis. To operationalise the “negotiated” dimension, we embedded relational contract theory during attribute mapping and maintained an audit trail linking refinements to theoretical rationale and contextual constraints. Results Nineteen studies met inclusion criteria. We extracted nine defining ACP attributes and organised them into an initial layered structure. Applying Macneil’s contract norms indicated that reciprocity was not explicit and that surrogate authority required clearer specification. Accordingly, we retained the nine attributes, revised Personal representative identification to Representative role clarification, and introduced Reciprocal exchange among stakeholders. The final negotiated ACP model comprises a core layer (Values and preferences clarification), an execution layer (Multi-party discussion, Organisational documentation support, and Guidance and information provision), and a safeguard layer (Regular review and updating, Managing uncertainty and conflict, Representative role clarification, Readiness assessment, Legal and policy alignment, and Reciprocal exchange among stakeholders). Conclusion Negotiated ACP is a structured, multi-party, explicitly documented, and revisable agreement-process whose practical authority depends primarily on relational and organisational governance rather than statute. The derived attributes and boundary cases provide a practical basis for identification, documentation standards, measurement development, and implementation work in non-statutory settings.