Background Advance care planning (ACP) provides an opportunity for older people to discuss and identify care at the end of life that is aligned with their preferences. ACP is a complex intervention, therefore its development and implementation requires evidence on the contextual factors in which implementation is planned. This study aims to identify potential contextual factors to ACP in long term care facilities (LTCFs) in China, and to develop recommendations to underpin future implementation.

Methods We conducted semi-structured interviews with residents, family members, and healthcare professionals in nursing homes. Reflexive thematic analysis was used to analyse data.

Results Four themes were generated from data collected with 12 residents, 10 family members, and 14 healthcare professionals. (1) ‘Death-denying communication’: cure-oriented understanding of medicine, bi-directional protection and lack of honest information sharing may hinder ACP initiation; (2) ‘Decision-making process aligning with family interests’: the guardian-centred decision-making model and potential ACP benefits and risks to family may influence engagement; (3) ‘Initiating ACP in a dynamic and individualised way’ may facilitate ACP through informal and indirect introduction, adapting to family structures, and making in-the-moment decisions; (4) ‘Building internal and external support’ may integrate ACP into practice by raising awareness and removing potential legal risks. Recommendations are proposed based on four themes and Social Ecological Model.

Conclusion To promote ACP in LTCFs, it is important to capture spontaneous conversation triggers, recognise the integrity of guardianship and create a safe climate. Our findings inform our ACP development programme in China, and offers relevance to other Asian countries.