As populations around the world age, ensuring high-quality care and meaningful end-of-life experiences for older adults has become a pressing public health priority. Advance care planning (ACP) has been shown to improve end-of-life care, minimize unnecessary medical interventions, and reduce stress for family members. In nursing homes, however, the engagement of residents and their families in ACP is influenced by a range of personal, cultural, and organizational factors. This review and meta-synthesis aimed to synthesize qualitative evidence on how nursing home residents and their families experience and perceive ACP, identifying challenges, facilitators, and practical insights to inform strategies for more effective ACP implementation. A systematic search was conducted in PubMed, Web of Science, Embase, EBSCO, The Cochrane Library, Sinomed, CNKI(China National Knowledge Internet), and WanFang (up to October 2024) to locate qualitative and mixed-method studies (qualitative data only) on ACP experiences in nursing home settings. Studies were eligible if participants were residents or family members, the publication was in English or Chinese, and the study included qualitative data. Methodological quality was assessed using the Joanna Briggs Institute checklist for qualitative research. Thematic synthesis was applied to integrate findings across studies, following ENTREQ and PRISMA guidance. From 1,097 records, 21 studies were included. Analysis revealed three central themes: (1) attitudes toward ACP among residents and families, (2) individualized needs and preferences for ACP, and (3) factors influencing ACP implementation. Most participants valued ACP for fostering communication and emotional expression and recognized its educational benefit. Nonetheless, some family members expressed ambivalence or reluctance. ACP needs were highly individualized, shaped by personal and contextual factors. Effective facilitators included accessible information, adequate cognitive capacity, supportive policies, an open cultural climate, empathetic multidisciplinary teams, and strong trust between residents, families, and staff. Nursing home residents and their families increasingly acknowledge ACP as valuable for expressing care preferences and supporting meaningful communication. Cultural sensitivities and sociocultural norms, however, can limit participation. To enhance ACP uptake, policymakers and healthcare organizations should strengthen legal frameworks, provide clear guidelines, and ensure tailored decision-support resources. Training staff in compassionate communication and fostering interdisciplinary collaboration are also essential to meet the diverse needs of nursing home populations.
