Background Decision-making in cancer care is increasingly complex as therapeutic options increase alongside ongoing ambiguity about acceptable outcomes for patients with advanced illness. Unexpected patient deterioration may necessitate difficult conversations and ad hoc decision-making, contributing to significant patient and family distress.

Aim and methods This paper will discuss findings from early phase 1 and 2 data that developed and pilot tested an advance care planning intervention for cancer patients using a combination of methods: the vignette technique, a guided intervention by a skilled facilitator and a mixed methods research approach to allow for an integration of process and outcome evaluation.

Results Our studies have demonstrated that repeated invitations for participation in ACP may elicit distress in some cancer patients and many patients continue to be reticent about completing formal ACP documentation.

Discussion We continue to advocate for the ethical principal of “respect for persons” over patient autonomy in view of the distinct variability in patients’ wishes to be involved in end of life discussions and decision making.