Background Conversations about end-of-life (EOL) care offer individuals opportunities to consider future treatment options in accordance with their values. While there are many reports focusing on community-based interventions for initiating early EOL planning behaviours in non-terminally ill adults, these interventions’ effects are poorly understood. This study provides a comprehensive review and analysis of community-based interventions for initiating early ACP conversations and increasing EOL planning behaviours.

Methods Medline, EMBASE, CENTRAL, PsycINFO and CINAHL were searched for relevant articles. for all two-armed studies, dichotomous data were analysed using meta-analysis of binary outcomes to calculate risk ratios (RR) and their 95% confidence interval (95%CI). for continuous measures, the standardized mean difference (SMD) and 95%CI were calculated with the inverse variance method. Quality of studies was appraised using the National Institute for Health and Care Excellence checklist and a thematic synthesis was conducted with the Theory of Planned Behaviour model.

Results 53 studies (34735 patients) that utilised interventions classified as workshops, 1-to-1 counselling, discussion groups, modified AD, complex methods, distribution of printed or online materials, were included in this study. In single-arm studies, pooled pre-post comparison of EOL test scores showed a significant benefit of EOL interventions with considerable heterogeneity (SMD=0.59, 95%CI=0.36–0.82, I2=78%, p<0.001). Within two-arm studies comparing EOL test scores, there was a trend towards overall benefit for EOL interventions (SMD=0.35, 95%CI= -0.01–0.72, I2=75%, p=0.060), although insignificant by a small margin. The comparison of EOL behaviours between both arms favoured EOL interventions over control (RR=2.40, 95%CI=1.27–4.53, I2=98%, p=0.007). In our thematic analysis, the interventions target different elements of behavioural change.

Conclusion This study reviews the most effective strategies in the community to initiate EOL conversations for non-terminally ill adults. These strategies modify different behavioural aspects of an individual’s intention to initiate EOL conversations and have proven to increase both EOL knowledge and behaviour.