Background Despite technological advances, mortality in intensive care units (ICUs) remains significant. Patients receiving critical care often experience the sudden onset of life-threatening symptoms. Although, a significant development of Advanced Care Planning (ACP) is observed, inadequate ACP support is provided to ICU patients. Variation of implementation across different countries is documented and needs to be understood.

Methods Qualitative, semi-structured, in-depth interviews with 30 health care professionals (ICU consultants/nurses, Palliative Care clinicians and academics) from both UK (15) and Japan (15). The data was analyzed using thematic analysis and qualitative comparative analysis, as ACP can be context specific.

Results Withdrawal and/or withholding of treatment were perceived to be the key clinical decisions, relevant to ACP discussions and advanced directive documentation. Different perspectives on those practices, different clinical protocols and legal frameworks were found to influence the framework of ACP implementation for ICU patients. Differences in communication styles between clinicians, patients and families have also informed different preferences. UK clinicians considered withdrawal of treatment within 72 hours after patient ICU admission, whereas Japanese colleagues favored less withdrawal of treatment options. Patient-centered vs family-centered decision-making cultures in the two countries, seem to suggest that UK clinicians consider advanced directives documents more favorably than their Japanese counterparts. The legal status of advanced directives in the UK only, might also explain this discrepancy. Nevertheless, preferences with regards to Do-not-attempt-to resuscitate (DNAR) decisions seem to be more agreeable by both countries.

Conclusions Several parameters related culture perspectives on end-of-life care, communication practices, alongside legal frameworks and clinical protocols influence the form and applicability of ACP in the ICU context. Development of ACP should take into considerations those context specific values and preferences when initiating ACP in ICU within different countries. Integrating Palliative care in ICU, might support the appropriate ways of ACP implementation.